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THE ;  E  AE 

t— — ^ 

AND    ITS    DISEASES 


BEING 


PRACTICAL    CONTRIBUTIONS    TO    THE    STUDY    OF 

OTOLOGY 


/  BY 

SAMUEL    SEXTON,   M.D., 

Al'RAL    SURGEON    TO    THE     NEW    YORK    EYE     AND     EAR    INFIRMARY;    FELLOW    OP    THE  AMERICAN 

OTOLOGICAL     society;     fellow      of     the     NEW     YORK     ACADEMY      OF     MEDICINE; 

MEMBER  OF  THE   MEDICAL  SOCIETY  OF  THE  COUNTY  OP  NEW  YORK, 

AND  THE  practitioners'  SOCIETT  OF  NEW  YORK 


EDITED  BY 

CHRISTOPHER    J.    COLLES,    M.D., 

ASSISTANT  AURAL  SURGEON  TO  THE  NEW  YORK  EYE  AND  EAR  INFIRMARY 


WITH   NUMEROUS  ORIGINAL.  ILLUSTRATIONS 


NEW    YORK 

WILLIAM      WOOD      &      COMPANY 

56  &  68  Lafayette  Place 

1888 


\X)\/3lOO 


I  Copyright  by 
WILLIAM    WOOD    &    COMPANY. 


PRESS  OF 

STETTINER,    LAMBERT     A    CO., 

C2    24  «  it  READE  8T  , 

NEW  YORK. 


PREFACE. 


The  Author  has  not  attempted  to  present  to  the  profession  a 
treatise  on  •  the  ear  embracing  the  entire  field  of  otology,  but  he 
trusts  that  the  particular  subjects  embraced  in  the  work,  and  to 
which  he  has  directed  more  special  attention,  may  be  found  of  ser- 
vice to  those  interested,  whilst  not  devoid  of  interest  to  the  otolo- 
gist. To  the  Author's  early  acquired  vogue  of  noting  in  detail 
matters  of  practical  interest  in  private  and  hospital  practice  is  due 
the  accumulation  of  the  records  of  some  ten  thousand  aural  cases, 
or  about  one-third  of  all  such  that  have  passed  through  his  hands 
during  the  past  twenty  years.  It  is  at  the  earnest  request  of  his 
professional  friends,  and  many  of  the  practitioners  and  students 
who  have  attended  his  aural  clinics  at  the  N^ew  York  Eye  and  Ear 
Infirmary,  and  formerly  at  the  New  York  Ear  Dispensary,  that  he 
has  been  induced  to  select  from  this  and  from  his  published  writings, 
the  material  of  which  this  work  is  composed. 

The  labor  of  co-ordinating  the  immense  accumulation  of  clinical  . 
material  would  scarcely  have  been  undertaken  but  for  such  encour- 
agement, and  the  valuable  aid  of  his  assistants  in  hospital  work.  To 
the  latter,  namely,  Drs.  Wm.  A.  Bartlett,  Hobert  Barclay,  and  C. 
J.  Colles,  his  sincere  thanks  are  extended  for  faithful  work  on  his 
clinical  records  at  the  Infirmary,  and  their  assistance  in  preparing  a 
card  index  to  all  of  his  records,  comprising  some  forty  thousand 
reference  cards,  and  the  revision  and  classification  of  the  same,  and 
for  many  original  drawings  and  diagrams  to  illustrate  the  text. 

The  Author  has  abstracted  considerable  matter  in  the  prepara- 


U5'\ 


IV  PREFACE. 

tioii  of  the  work  from  his  more  practical  contributions  to  the 
medical  journals  of  the  day,  both  home  and  foreign,  during  the  past 
fifteen  years,  omitting  much  that  has  in  the  mean  time  become 
obsolete. 

In  studying  the  functions  and  diseases  of  the  ear,  it  has  been  en- 
deavored to  avoid  the  too  exclusive  consideration  of  local  conditions^ 
with  a  view  to  separate  treatment  apart  from  the  whole,  since  otol- 
ogy in  its  broadest  sense  should  embrace  a  consideration  of  the 
upper  air  tract,  of  which  the  middle  ear  forms  but  a  part,  and  of 
regions  contiguous  to  the  ear. 

Both  the  anatomy  and  physiology  of  the  ear  embrace  a  literature 
too  extensive  to  be  more  than  briefly  considered  in  the  scope  of 
this  work,  the  essential  anatomy  and  physiology  of  the  organ  only, 
therefore,  have  been  for  the  most  part  introduced  along  with  the  text, 
where,  it  is  believed,  they  will  best  serve  the  purposes  of  the  reader. 

The  writer  has  not  always  employed  the  term  "  chronic  catarrh  " 
in"^8peakingf  o  the  morbid  processes  of  the  mucous  membrane  usually 
known  by  that  name,  believing  that  it  does  not  in  every  case  fully 
describe  the  conditions  present. 

The  following  subjects  introduced  in  the  work  are  considered  as 
worthy  of  special  mention  here,  inasmuch  as  they  present  features 
not  usually  made  so  prominent  in  works  on  the  ear :  Catarrh  of  the 
upper  air  tract ;  Oral  irritation,  specially  dentition  and  diseased 
teeth,  and  Sea  bathing — their  causative  influences  on  the  ear. 
Wounds  and  injuries  of  the  ear,  occurring  in  warfare  and  civil 
life.  Rupture  of  the  drum-head  from  boxing  the  ears,  and  its 
medico-legal  aspect.  Concussion  from  the  blast  of  great  guns 
and  explosives,  etc.  Anomalies  of  audition,  noises  in  the  ears  and 
their  connection  with  insane  hallucinations  and  delusions.  [It  is 
hoped  that  in  thus  drawing  attention  to  some  unfortunate  persons 
who  have  symptoms  of  mental  aberration  wholly  due  to  "  noises  in 
the  head "  (ear  ?),  a  more  satisfactory  plan  in  their  treatment  may 
be  adopted.]  The  effects  of  false  hearing  on  singers,  actors,  lectur- 
ers, and  musicians  are  also  considered  in  this  connection.     Othse- 


PREFACE.  V 

matoraa  occurring  among  lunatics,  pugilists,  and  others  has  been 
presented  very  fully,  and  will,  it  is  believed,  be  of  special  interest 
to  alienists  and  examiners  in  lunacy. 

Tlie  operation  of  excision  of  the  drum-head  and  ossicles  for 
otorrhoea,  and  deafness  due  to  chronic  catarrh  of  the  middle  ear,  in- 
cluding a  full  account  of  the  literature  of  the  subject.  The  results 
of  this  operation  have  been  satisfactory,  and  it  is  hoped  that  its  use- 
fulness will  be  confirmed  by  experience. 

The  classilication  and  education  of  school  children  with  defective 
hearing. 

The  effect  of  high  atmospheric  pressure  on  the  ear  in  tunnels, 
caissons,  and  in  diving.  The  increase  of  submarine  labor  of  late 
years  makes  it  very  important  that  the  effect  of  such  work  on  the 
ear  be  understood. 

The  subject  of  pension  claims  of  soldiers,  sailors  and  marines  on 
account  of  disability  from  deafness  is  discussed. 

The  Writer  has  been  greatly  assisted  in  the  collecting  of  facts  re- 
lating to  the  effects  of  casualties  of  warfare  on  the  ear  by  officers 
of  the  army  and  navy,  and  he  trusts  that  they  may  continue  to  favor 
him  with  any  observations  bearing  on  this  subject  coming  to  their 
knowledge.  The  admirable  instruments,  of  which  cuts  are  given,, 
which  have  been  employed  in  the  Author's  practice,  were  made  by 
Mr.  W.  F.  Ford,  the  well-known  instrument-maker. 

Much  of  the  work  of  abstracting  the  writer's  papers,  translations, 
etc.,  revising  the  proof  sheets,  and  the  entire  preparation  of  the  index 
has  been  done  by  Dr.  Colles,  whose  name  appears  as  editor  on  the 
title  page  of  the  book. 

SAMUEL  SEXTON. 

12  West  35th  Street, 
New  York,  September,  1888. 


CONTENTS. 


PAET   I. 

REMARKS  ON  THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  AURI- 
CLE, EXTERNAL  AUDITORY  CANAL  AND  CONTIGUOUS 
PARTS,  AND  THE  MEMBRANA  TYMPANI. 

PAQK 
CHAPTER  I. 

The  Auricle.  The  External  Auditory  Canal.  The  Attachment  of  the  Au- 
ricle and  Cartilaginous  Canal  to  the  Temporal  Bone.  The  Auriculo- 
cranial  Muscles.  Relations  of  the  Temporo-Maxillary  Articulation  to 
the  Cartilaginous  Portion  of  the  External  Auditory  Canal.  Further 
Remarks  on  the  Exterior  Muscles  and  Fascia  of  the  Ear.  Observa- 
tions on  the  Comparative  Physiology  of  the  Auricle.  The  Functional 
Movements  of  the  Auricle.  The  Voluntary  Movements  of  the  Auricle 
in  Man 3 

CHAPTER  II. 

Observations  on  the  Transmitting  Mechanism  of  the  Drum  of  the  E^r : 
the  Drum  of  the  Ear;  the  Membrana  Tympani ;  the  Muscles  of  the 
Drum 35 

CHAPTER  III. 

The  Relations  of  the  Naso-Pharynx  with  the  Drum  of  the  Ear,  and  the 
ASration  of  the  Tympanum 43 

CHAPTER  IV, 

The  Sense  of  Hearing 54 

PART   II. 
CAUSES  OF  EAR  DISEASE. 

CHAPTER  V. 

Heredity,  Cachexia.  Age.  Occupation.  Defective  Personal  Hygiene. 
Syphilis.    Acute  Infectious  Diseases  :  Scarlet-fever,  Measles,  Variola, 


nil  CONTENTS. 

PAQE 

Diphtheria,  Cerebro-spinal  Meniugitis,  Mumps,  Pertussis,  Typhoid, 

"  Roman,"  and  other  fevers.     Cutaneous  Aflfections 61 

CHAPTER    VI. 

Catarrh  of  the  Upper  Air-Tract 71 

CHAPTER  VII. 

Oral  Irritation 89- 

CHAPTER  VIII. 

Bathing  in  the  Sea.  Fresh  Water  Bathing.  Russian,  Turkish,  and  other 
Baths.  Entrance  of  Water  into  the  Ears  by  the  Use  of  the  Nasal 
Douche,  Post-Nasal  Syringe,  Sniffing  up  of  Water,  etc.  Clipping  and 
Wetting  the  Hair  of  the  Head 100 

PAKT  III. 

WOUNDS,  INJURIES,    AND    DISEASES    OF    THE    EAR  AND    THEIR 

TREATMENT. 

CHAPTER  IX. 

Wounds  and  Injuries  of  the  External  Ear  :  Cleft  of  Lobule  ;  Othaema- 
toma ;  Gunshot,  Sabre,  and  Arrow  Wounds Ill 

CHAPTER  X. 

Wounds  and  Injuries  of  the  Drum-Head  and  Drum  of  the  Ear  :  Blows 
upon  the  Ear  with  the  Open  Hand  or  Fist ;  Blows  from  Missiles  ; 
Falls  upon  the  Ear  ;  Concussion  from  the  Blast  of  Projectiles  or  Great 
Guns  ;  from  the  Blast  of  Small  Arms  or  Small  Explosives  ;  from  long- 
continued  JIusketry  Fire,  Rapid  Firing  Machine  Guns,  etc.;  Impact 
of  Steam  Whistles,  Loud  Voice  or  other  Intense  Sounds,  as  Metal 
Hammering  ;  by  Contusion  or  Penetration  of  Objects  Thrust  into 
the  Ear  ;  by  Violent  Entrance  of  Water  in  Syringing  the  Ear  and  in 
Surf  Bathing ;  by  Violent  Traction  on  the  Auricle ;  by  Sudden  Con- 
densation of  Air  in  the  Drum 176- 

CHAPTER  XI. 

I 
Remarks  on  the  Anatomy  of  the  Middle  Ear 22T 

CHAPTER  Xn. 

Otitis  Media    Non-Suppurativa :    Acuta,    Subacuta,   Serosa,   Chronica, 

Syphilitica 233 

CHAPTER  Xni. 

Otitis  Media  Suppurativa  :  Acuta,  Chronica 260 


CONTENTS.  IX 

PAGE 
CHAPTER  XIV. 

Aural  Polypi 305 

CHAPTER  XV. 

Facial  Paralysis  Due  to  Affections  of  the  Ear  and  CJontiguous  Parts 312 

CHAPTER  XVI. 

Anomalies  of  Audition  :  Noises  in  the  Ear  ;  Autophonia,  Pseudacousma 
or  False  Hearing  ;  Effects  of  False  Hearing  on  Singers,  Actors,  Lec- 
turers and  Musicians ;  Certain  other  Anomalies  of  Audition ;  Dysa- 
cousma  or  Painful  Hearing;  Some  of  the  Relations  of  Certain  Aural 
Phenomena,  Hallucinations,  etc.,  to  Insanity  and  Brain  Aflfections. . .  324 

CHAPTER  XVn. 

The  Operation  of  Excision  of  the  Drum-head  and  Ossicles 358 

PART   IV. 

MISCELLANEOUS  ARTICLES. 

CHAPTER  XVIII. 

The  Education  of  School  Children  with  Defective  Hearing.  Remarks  on 
the  Extent  of  Deafness  in  the  Schools.  Deafness  among  School 
Teachers 397 

CHAPTER  XIX. 

On  the  Effect  of  High  Atmospheric  Pressure  on  the  Ear,  in  Tunnels,  Cais- 
sons, etc.  On  the  Effect  of  Submarine  Diving  on  the  Ear.  On  the 
Effect  of  Sudden  Rarefaction  of  Air  Externally  to  the  Drum 428 

CHAPTER  XX. 

Injurious  Effects  of  Unskilful  Treatment  of  the  Ear,  especially  from  Ef- 
forts to  Remove  Foreign  Bodies 435 

CHAPTER  XXI. 

Claims  of  Soldiers,  Sailors  and  Marines  for  Pensions  on  account  of  Disa- 
fSfi  bility  from  Deafness 445 


LIST  OF  ILLUSTRATIOl^S. 


Fig.  paob 

1.  The  Auricle  (Burnett),  .......        8 

2.  Muscles  of  the  External  Ear  (Henle),  .....  7 

3.  Cartilage  and  Muscles  on  the  Inner  Face  of  the  Auricle  (Henle),         .        7 

4.  Section  through  External  Auditory  Canal  (Henle),  .  .  8 

5.  Cast  of  the  External  Auditory  Canal  (Bezold),     ....        9 

6.  Cast  of  Auricle  and  External  Auditory  Canal  (Bezold),        .  .  9 

7.  Muscles  of  the  Cranium  (Henle),  .  .  .  .  .14 

8.  Muscles  of  the  Head  (Sappey),  .....  15 

9.  Outpr  Surface  of  Drum-Head  (Gruber),     .  .  .  .  .36 

10.  Inner  Surface  of  Drum-Head  (Gruber),  ....  66 

11.  Muscles  of  the  Soft  Palate  (Gray),  .  .  .  .  .44 
13.  Diagram  of  the  Upper  and  Lower  Respiratory  Passages,     .            .  45 

13.  Diagrammatic  Scheme  of  the  Conduit  passing  from  the  Throat  to 

the  Auricle,  ........      46 

14.  Diagram  of  the  Upper  Respiratory  Tract  and  its  Air  Chambers,     .  72 

15.  Diagram  of  the  Tympanic  Plexus  (Riidinger),      .  .  .  .88 

16.  Casts  of  the  Teeth  of  a  School-Girl,       .....  90 

17.  Casts  of  Upper  and  Lower  Teeth  of  a  Youth,       .  .  ,  .91 

18.  Lower  Jaw,  showing  horizontal  position  of  "Wisdom  Teeth,  .  93 

19.  Casts  of  Teeth  of  a  Boy,      .......      94 

20.  Othaematoma  of  Right  Auricle  of  a  Man,        ....  139 

21.  Likeness  of  an  Insane  Male  Patient  with  Othsematoma  of  Right 

Auricle,      .........     142 

22.  Othsematoma  and  Post-Auricular  Abscess  in  the  same  Patient,     .  148 

23.  Deformity  of  Left  Auricle  fi'om  Othsematoma,  in  a  Man,         .  .     144 

24.  Deformity  of  Left  Auricle  from  Othsematoma,  in  a  Man,    .  .  144 

25.  Likeness  of  a  Woman,  showing  Othsematoma  of  Left  Auricle,  .     148 

26.  Othsematoma  of  Right  Auricle  of  a  Man,        ....  149 

27.  Sinus  through  Mastoid  behind  Auricle  leading  into  Tympanum, 

from  a  Gun-shot  Wound,  ......     155 

28.  Deformity  of  Auricle  severed  from  its  Attachments  by  a  Cart 

Wheel, 173 

29.  View  from  behind  of  same  Patient's  Head,  showing  altered  posi- 

tion of  Severed  Auricle,  ......       174 

80.  Scene  of  the  Shell  Explosion,  Sandy  Hook,  October  21st,  1886,      .  195 

31.  Diagram  of  Gun-Carriage  and  Platform,  showing  position  of  Men, 

Direction  of  Wind,  etc.,  at  time  of  the  Explosion,  -.  .  .     196 


Xll  LIST    OF    ILLUSTRATIONS. 

FIG.  PAGE 

33.  Right  Drum-Head  of  a  Soldier,  injured  by  the  Explosion,  ,            .  198 

33.  Left  Drum-Head  of  a  Soldier,  injured  by  the  Explosion,           .            .  199 

34.  Left  Drum-Head  of  a  Soldier,  injured  by  the  Explosion,     .            .  301 
85.  Right  Drum-Head  of  a  Soldier,  injured  by  the  Explosion,        .            .  801 

36.  Right  Drum-Head  of  a  Man,  injured  by  the  Explosion,        .            .  302 

37.  Left  Drum- Head  of  a  Soldier,  injured  by  the  Explosion,          .            .  304 

38.  Left  Drum-Head  of  a  Soldier,  injured  by  the  Explosion,     .            .  205 

39.  View  from  within  of  the  Outer   Portion   of   the   Left  Temporal 

Bone(Leidy),            .            .            .            .            .            .            .          .  228 

40.  Section  of  the  Left  Temporal  Bone  through  the  Squamosa  (Leidy),  338 

41.  Cast  of  Eustachian  Tube  and  Middle-Ear  (Bezold),         .  .  .229 
48.  View  from  within  of  the  Right  Tympanum  and  Contiguous  Parts 

(Henle),              .            .                         .....  230 

43.  Author's  Knife  for  Making  Incision  into  the  Attic,        .            .            .  277 

44.  Sinuses  Leading  through  Mastoid  Cortex  from  Antrum  and  Tym- 

panum, in  a                               ......  290 

45.  Diseased  Temporal  Bone,   resulting  from  Chronic  Purulent  Otitis 

Media,  in  an  Infant,         .......  397 

46.  Author's  Combination  Ear  Forceps,     .....  300 

47.  Author's  Glass  Aural  Syringe,        ......  301 

48.  Author's  Polypus  Snare,            ......  310 

49.  Likeness  of  a  Girl  with  Right  Facial  Paralysis,              .            .            .  316 

50.  Same  Patient,  Endeavoring  to  Laugh,            ....  316 

51.  Likeness  of  a  Man  with  Bilateral  Facial  Paralysis,         .            .            .  317 

52.  Same  Patient  endeavoring  to  close  the  Mouth  and  Eyes,     .            .  317 

53.  Electric  Head  Lantern  for  Operations  upon  the  Ear,      .            .            .  369 

54.  Storage  Battery  for  Electric  Lantern,             ....  370 

55.  Trowel-shaped  Knife,  used  by  the  Author  in  Excising  the  Drum- 

Head  and  Ossicles,      .  .  .  .  .  .  .371 

56.  Blunt-pointed,  Narrow  Bladed  Knife,  used  by  the  Author  in  same 

operation,              ........  371 

57.  Angular  Bladed  Knife,  used  by  the  Author  for  dividing  the  Right 

Incudo-Stapedial  Articulation,         .....  371 

58.  Angular  Bladed  Knife,  used  by  the  Author  for  dividing  the  Left 

Incuda-Stapedial  Articulation,  ......  371 

59.  Author's  Instrument  for  Amputating  the  Long  Process  of  the  In- 

cus,       .........  386 


PART    FIRST. 


REMARKS  ON  THE  ANATOMY  AND  PHYSIOLOGY  OF  THE 
AURICLE,   EXTERNAL  AUDITORY   CANAL  AND 
CONTIGUOUS    PARTS,   AND    THE 
.      MEMBRANA  TYMPANL 


CHAPTER    I. 

The  auricle.  The  external  auditory  canal.  The  attachment  of  the  auricle 
and  cartilaginous  canal  to  the  temporal  bone.  The  auriculo-cranial  muscles. 
Relations  of  the  teraporo-maxillary  articulation  to  the  cartilaginous  por- 
tion of  the  external  auditory  canal.  Further  remarks  on  the  exterior  mus- 
cles and  fascia  of  the  ear.  Observations  on  the  comparative  physiology  of 
the  auricle.  The  functional  movements  of  the  auricle.  The  voluntary 
movements  of  the  auricle  in  man. 

THE  AUKICLE. 

The  cartilaginous  expansion  at  the  outer  terminus  of  the  ear  con- 
stitutes the  auricle  and  outer  portion  of  the  extei'nal  auditory  canal. 
The  functions  and  diseases  of  these  parts  are  similar  and  will,  there- 
fore, be  considered  somewhat  in  connection  with  each  other. 


Fig.  1. — The  Auricle  (from  BuRNim), 
a,  Helix;   c,  antihelis;    6,  fossa  of  the  helix;   d,  fossa  of  the  antihelix;   e,  tragus;    /,  anti- 
tragus;  /i,  lobule;  g,  concha. 

The  pinna,  or  wing  of  the  ear,  as  the  auricle  is  sometimes  called,  la 
topographically  entirely  unlike  any  other  region  of  the  body,  consist- 
ing as  it  does  of  a  delicate  but  firm  cartilaginous  framework  which  is 


4  THE    AURICLE. 

much  exposed  because  of  its  prominently  outstanding  position.  This 
pavilion  varies  in  size  and  shape  in  different  individuals  ;  in  general 
contour  it  is  hollowed  out  like  a  shell ;  the  concha  proper,  the  deep- 
est part,  is  the  expansion  with  which  the  external  auditory  canal 
■commences.  The  auricle  is  twenty-three  to  thirty  lines  in  length, 
thirteen  to  twenty-eight  in  its  greatest  width,  and  from  one-half  to 
two  or  three  lines  in  thickness. 

It  stands  out  from  the  skull  at  an  angle  of  from  30°  to  40°,  the 
angle  being  more  acute  forward  and  above  than  behind.  It  rarely 
happens  that  this  angle  is  less  than  10°  or  greater  than  45°.  The 
form  of  the  auricle  is  very  irregular  in  consequence  of  the  foldings  of 
its  cartilage.  It  is  well  adapted  to  the  collection  of  sound  and  from 
its  general  outspreading  shape  aids  in  affording  tension  to  the  trans- 
mitting apparatus  of  the  drum.  It  is  sufficiently  movable  in  its 
attachment,  and  pliable,  to  be  safely  pressed  against  the  head  when 
lain  upon. 

The  irregularities  of  the  auricle's  surface,  due  to  foldings  of  the 
cartilage,  while  presenting  a  pretty  uniform  appearance  to  casual  in- 
spection, are  on  closer  observation  found  to  be  differently  moulded 
in  almost  every  subject.  So  characteristically  distinct  is  this  varia- 
tion that  for  personal  identification  a  photograph  of  the  organ  would 
often  serve  a  better  purpose  than  one  of  the  face,  since  the  former  is 
less  subject  to  the  mutations  of  time  or  other  changes  to  which  the 
latter  is  liable. 

Significance  of  the  auricle's  configuration.  Without  doubt  the 
large  auricle  is  more  serviceable  acoustically,  its  ample  receiving  sur- 
face favoring  the  collection  of  sound  (and  probably  also  the  apprecia- 
tion of  its  source)  ;  but  most  persons  would  willingly  exchange  any 
advantage  of  this  kind  for  the  possession  of  a  small  and  shapely 
organ  which  is  considered  an  evidence  of  aristocratic  ancestry.  The 
size  and  shape  of  the  auricle,  however,  usually  depends  on  the 
general  configuration  of  the  individual,  and,  consequently,  some  indi- 
viduals of  every  race  or  social  station  have  small  and  handsomely 
formed  ears.  The  ear  in  negroes  is  an  exception  to  the  above  in  this, 
that  the  organ  is  smaller  than  in  other  races. 

Both  ancient  and  modern  writers  have  attached  much  significance 
to  the  size  and  figure  of  the  auricle  and  its  angle  of  attachment  to 
the  head  ;  thus  idiots  and  imbeciles  are  said  to  often  have  peculiar 
ears,  a  statement  not  warranted  by  the  facts — congenital  defects  of 
the  organ  by  no  means  being  always  or  indeed  common  among  them. 
The  observations  of  physiognomists  in  regard  to  the  significance  of 
the  ears  in  determining  character,  do  not  hold  true  beyond  the  fact 


THE   AUKICLE.  5 

that  they  maintain  a  very  constant  configuration  in  individuals  of 
similar  physical  development,  irrespective  of  race. 

Charles  Darwin,  in  his  untiring  search  for  evidence  of  man's  evo- 
lution, discovered  a  morphological  correspondence  between  man  and 
monkey,  namely,  the  frequent  occurrence  of  an  irregularity  in  the  car- 
tilage forming  the  superior  border  of  the  helix  of  man's  ear  corre- 
sponding with  the  more  unvarying  pointed  ear  in  some  species  of 
monkeys. 

The  acoustic  value  of  the  auricle  is  not  accurately  known,  although 
it  has  been  the  subject  of  much  discussion.  Military  surgeons  and 
other  authorities  have  asserted  that,  where  the  organ  has  been  entirely 
removed  by  wounds  or  by  design,  no  loss  of  hearing  occurs.  It  is 
probable,  however,  that  in  the  cases  observed,  the  hearing  power  was 
not  accurately  tested  either  before  or. after  the  injury.  The  absence 
of  auricles  must  entail  some  defectiveness  in  hearing,  especially  in 
respect  to  orientation,  since  those  who  have  been  deprived  of  the 
organ  frequently  use  the  palm  of  the  hand  as  a  substitute. 

The  auricle  and  external  auditory  canal  constitute  a  uon-resonant 
natural  trumpet,  whose  smooth  and  generally  concave  surface  con- 
denses sound-vibrations  approaching  the  drum-head  ;  even  the  folds 
of  the  auricles  are  believed  to  reflect  and  thus  intensify  sound  in  its 
passage  to  the  concha. 

TJie  Helix,  incurving,  affords  a  border  to  almost  the  entire  circum- 
ference of  the  auricle.  On  its  outer  face  the  helix  begins  in  the  bottom 
of  the  concha,  dividing  it  into  two  unequal  portions,  the  lower  one  being 
larger  than  the  upper.  This  horizontal  portion  of  the  helix  is  called 
its  spiiie;  it  presents  a  short  pointed  prolongation  on  reaching  the 
anterior  edge  of  the  auricle,  and  from  thence  it  (the  cms)  curves  up- 
wards, forming  the  anterior  border  of  the  auricle ;  the  helix  then 
circles  around  the  summit  of  the  auricle  to  terminate  behind  and 
below  in  the  cauda  helicis. ' 

The  Antihelix  is  a  fold  of  cartilage  situated  within  the  helix,  com- 
mencing just  above  the  antitragus,  passing  upwards  and  describing  a 
semicircle,  the  convexity  of  which  corresponds  with  the  concavity  of 
the  helix.  It  terminates  anteriorly  by  two  diverging  branches,  the 
space  between  which  forms  the  fossa  of  the  antihelix.  The  space  be- 
tween the  helix  and  antihelix  is  t\\Q  fossa  of  the  helix. 

The  Tragus  is  called  thus  from  supporting  a  bunch  of  hair  more  or 
less  prominent  in  persons  of  advanced  years. 

The  Antitragus  lies  opposite  the  tragus  and  behind  the  meatus. 

'  In  mammifera  it  constitutes  a  separate  cartilage,  the  scutulum.  Huschke. 
Splanchnologie,  Paris,  18i5,  p.  749. 


6  TKB  AUSICLE. 

The  cartilage  of  the  antitiagns  is  mach  smaller  than  that  of  the 
tragus. 

Tke  (hncha  is  the  largest  of  aU  the  fossae  of  the  external  ear,  being 
bounded  behind  bj  the  antihelix,  and  below  continuons  with  the  ex- 
ternal anditorj  meatos. 

Tie  iimerfaee  of  ike  auride  poeaeeses  many  irregolarities  which 
corre^iond  with  those  of  its  onter  face.  The  most  prominent  eleva- 
tion, the  convexitj  of  the  concha,  affords  attachment  for  the  abdaetor 
mnscle  of  the  ear.  The  greater  portion  of  the  concha  is  applied  to 
the  side  of  the  head,  the  posterior  superior  portion  onlj  being  free. 

The  Lobe  is  a  cntaneoos  cushion,  flaccid  and  without  cartilage,  its 
free  border  extending  from  the  tail  of  the  helix  behind  to  the  skin 
ooTering  the  articulation  of  the  lower  jaw.  Its  sixe  is  determined  in 
different  individuals  bj  its  dependence  and  the  varying  amount  of  fat 
in  its  connective  tissue. 

The  Oeartilageot  the  auricle  is  soft,  spongy,  and  elastic,  its  cartilagi- 
noos  oeIl%  according  to  Huschke  and  others,  lying  in  a  retiform 
tiaBue.  Hnachke  found,  on  maceration  and  removal  of  its  perichon- 
drium, that  it  was  very  brittle,  so  that  the  thin  edge  of  the  helix 
oouM  be  with  difficulty  obtained  intact ;  he  states  also  that  there  is 
little  tendency  to  OBwification  in  the  progreas  of  age.  Tkependkon^ 
drium  is  firmly  adherent  to  the  cartilage.  The  skin  enveloping  the 
ear  is  separated  from  the  perichondrium  by  a  thin  layer  of  connee- 
tive  tissue ;  it  is  continuous  with  the  lining  of  the  external  auditory 
canaL  Its  attachment  to  the  cartilage  throughout  permits  of  a  slight 
moTonent,  but  the  covering  of  the  lobule  moves  much  more  freely. 
The  ddn  is  freely  supplied  with  sebaceous  glands  which  become 
larger  in  aaxe  and  more  numerous  in  approaching  the  external  andi- 
torj meatus.  The  secretion  of  these  glands  increases  in  the  same  pro- 
portion, assuming  finally,  deeper  in,  chemically,  the  character  proper 
to  the  glands  of  this  region. 

Hairs  are  most  abundant  on  the  outer  face  of  the  auricle ;  they 
are  especially  numerous  and  stiff  on  the  tragus  of  the  male.  Yary- 
ing  in  length  from  an  inch  to  an  inch  and  a  half,  they  curl  irregu- 
larly, turning  sometimes  into  the  external  auditory  canaL 

Muodes  of  the  auride.  With  the  exception  of  the  helicis  major 
these  muadea  do  not  seem  to  exert  any  influence  upon  the  tendon  of 
the  transmitting  mechanism.  On  the  outer  face  of  the  concha  are  the 
ieUeis  major  and  minor  mu*dee  ;  the  'former  is  interwoven  at  its 
broad  upper  end  with  the  superior  auricular  muscle,  and  attached 
loosely  at  its  small  end  to  the  onter  edge  of  the  helix  and  spine  of  the 
latter.     The  helicis  minor  aids  the  above. 


THE    AURICLE. 
1 


Fig.  2.— Muscles  of  thk  External  Eab  (fbom  EtaxLi). 
1,  Aiiricularis  superior;  2,  helicis  major;  3,  helicis  minor;  4,  spina  helicis;  5.  fibres  of  the 
tragicus  muscles  sometimes  attached  to  the  spine  of  the  helix;  8,  trapicus;  7,  incisura  auris;  8, 
antitragicus. 

3 


Fig.  3.— Cartilage  and  Muscles  ox  the  inner  Face  of  the  Auricle  (fbom  Hknls). 
1,  Eminence  made  by  the  triangular  foesa:  2.  obUquus  auriculse;  3,  eminence  made  by  the  fossa 
of  the  concha;  4,  cartilage  of  the  external  auditory  canal;  ♦,  its  surface  of  attachment  to  the 
edge  of  the  bony  canal;  5,  cartilage  of  the  pinna;    6,  cauda  helicis;  7,  transversus  auricols; 
8,  eminence  made  by  the  scaphoid  fossa . 


THE    EXTERNAL   AUDITORY   CANAL. 


The  antitragicus  muscle  sends  fibres  to  the  upper  edge  of  the  pos- 
terior surface  of  the  posterior  wall  of  the  cartilaginous  canal  (Henle); 
some  of  its  fibres  are  inserted  into  the  processus  caudatusof  the  lielix. 
The  tra^icus  muscle  is  short  and  lies  on  the  outer  surface  of  the 
tragus  ;  its  flattened  fibres  take  a  vertical  direction. 

On  the  inner  face  of  the  auricle  are  the  ohliquus  and  transversus 
auriculcB  muscles.  Like  the  tragicus,  these  muscles  are  in  man  quite 
insignificant. 

THE    EXTERNAL    AUDITORY    CANAL. 

The  external  auditor}'  canal  extends  from  the  bottom  of  the  concha  to 
the  membrana  tympaui,  and  consists  of  an  outer,  cartilaginous  portion, 
and  an  inner,  bony  portion,  the  latter  being  the  longer.  The  size  of 
the  canal  varies  much,  its  length,  according  to  Huschke,  in  adults 
being  from  ten  to  seventeen  lines,  its  height  four  to  six  lines,  its 
width  three  lines.  The  length  of  the  inferior  wall  of  the  osseous  por- 
tion is  much  increased  by  the  inclination  of  the  membrana  tympani. 

2       3 

i 


CM 


CM 

Fig.  4. — (From  Henle.) 
Section  through  the  External  Auditorj*  Canal  at  the  junction  of  the  Cartilage  of  the  Auricle, 
CC,  with  that  of  the  External  Auditory  Canal,  from  the  upper  wall  of  which  a  small  strip,  CM', 
remains;  CM",  inferior  wall  of  the  cartilage  of  the  canal;  H",  spina  heUcis;  L,  lobe  of  the  ear; 
1,  M.  epicranius  temporaUs;  2,  M.  auricularis  superior;  3.  M.  temporalis;  4,  superior  wall  of  the 
bony  canal;  5,  cavity  of  the  tympanum;  6,  membrana  tympani;  7,  stapes;  8,  vestibule;  9, 
meatus  auditorius  intemus  and  acoustic  nerve;  10,  inferior  wall  of  the  bony  canal;  11,  parotid 
gland ;  *,  fibrous  lip  of  the  border  of  the  bony  canal 


THE    EXTERNAL    AUDITORY    CANAL.  y 

The  Cartilaginous  Portion.  In  direction,  this  portion  of  the  canal, 
from  without  inwards,  passes  forwards  and  upwards,  and  is  somewhat 
twisted  upon  itself;  owing  to  these  inflections,  an  inspection  of  the 
drum-head  cannot  always  be  made  without  straightening  the  canal 
by  lifting  up  the  auricle.  At  the  commencement  it  is  largest  ante- 
riorly, being  composed  of  a  large  and  irregular  quadrilateral  plate  of 
cartilage,  with  rounded  angles,  forming  first  the  tragus  in  front  of 
the  orifice,  and  then  sweeping  inwards  to  form  the  anterior  and  lower 
wall  of  the  canal.  The  plate  is  turned  up  upon  itself,  and  lies  close 
to  the  posterior  face  of  the  concha.  It  may  be  felt  during  dissection 
by  pressing  the  forefinger  between  the  back  of  the  concha  and  the 
mastoid  process. 

5 


Fig.  5.— Cast  of  the  Auditory  Canal  Viewed 
Fi^oM  Above  (from  Bezold'). 
1  and  2,  First  and  Second  Curvatures  of  the 
canal;  3,  S-shaped  Curvature  of  the  concha;  4, 
fossa  intercruralis;  5,  fossa  scaphoidea. 


Fig.  6.— Cast   of   the  AriRicLE  and  Auditoby 

Canal    Viewed    prom   Within;   Face   op 

Drum-head;   Canal  foreshortened  (from 

Bezold  >. 

1.  Drum-head;   2,  second   curvature   of   the 

canal;  3,  upper,  3',  .lower  part  of  the  concha; 

4,  fossa  intercruralis;  5,  fossa  scaphoidea. 


The  inner  surface  of  this  plate  is  attached  to  the  rough  margin  of 
the  auditory  process  of  the  tympanic  plate  which  forms  the  inferior 
anterior  border  of  the  bony  meatus.  The  posterior  superior  wall  of 
the  canal  is  formed  by  that  portion  of  the  cartilage  which  is  folded 
back  upon  itself  from  the  anterior  edge  of  the  concha,  and  by  mem- 


'  Die  Corrosions-Anatomie  des  Ohres.     Friedrich  Bezold.     Munchen,  1882. 


10  THE    EXTERNAL    AUDITORY   CANAL. 

branous  tissue  which  serves  to  complete  the  closure  of  the  anterior 
inferior  cartilaginous  canal;  it  extends  backwards  about  three-quar- 
ters of  an  inch  to  be  firmly  attached  to  that  portion  of  the  rough 
surface  of  the  auditory  plate  forming  the  posterior  superior  border  of 
the  osseous  meatus. 

Pressure  in  front  of  the  tragus  usually  closes  the  lumen.  In  ad- 
vancing years,  and  always  in  some  subjects,  the  posterior  edge  of  the 
meatus  impinges  upon  the  lumen,  and,  in  thus  closing  the  outlet, 
sometimes  prevents  the  natural  escape  of  cerumen.  Owing  to  this 
valve-like  arrangement,  however,  the  entrance  of  foreign  bodies  is 
difficult.  In  children,  where  the  meatus  is  often  less  obstructed  in 
this  manner,  objects  are  more  easily  introduced. 

The  more  striking  topographical  features  of  the  cartilaginous  canal 
are  a  considerable  hollow  in  the  membranous  upper  part,  and  the  fis- 
sures forming  interruptions  on  its  sides  completely  dividing  the  car- 
tilage into  three  half  rings,  resembling  the  divisions  in  the  cartilage 
of  the  trachea. 

Between  each  couple  of  rings  is  found  a  fissure  or  so-called  incisura 
Santorini,  closed  by  fibrous  elastic  tissue.  The  exterior  fissure  is 
three  or  four  lines  distant  from  the  edge  of  the  tragus;  it  commences 
at  a  narrow  part  on  the  anterior  face  of  the  cartilage,  and  terminates 
on  the  superior  face,  being  here  from  one-half  to  one  line  in  width. 

The  interior  fissure  occupies  the  inferior  face,  extending  itself  a 
little  on  the  posterior;  it  is  one  to  one  and  one-half  lines  from  the 
preceding  and  larger  at  its  middle.  In  rare  cases  there  may  be  a 
third  smaller  fissure. 

The  M.  incisurm  Santorini,  M.  intertragicus  (Jung),  or  dilator 
muscle  of  the  concha  (Theile),  is  placed  above  the  larger  fissure.  It 
lies,  according  to  Henle,'  inferiorly  and  medianly  to  the  tragicus 
muscle,  on  the  anterior  surface  of  the  anterior  wall  of  the  cartilaginous 
canal,  and  passes  over  the  lateral  incision  of  the  cartilage.  The  last- 
named  author  says  that  Theile  found  this  muscle  very  distinct  in  a 
case  in  which  the  tragicus  muscle  was  present  in  a  very  rudimentary 
state  only. 

A  branch  of  the  stylo-glossus  muscle  is  sometimes  connected  with 
the  cartilage  of  the  canal.  Henle,''  in  describing  this  muscle,  says  its 
auricular  head  {Caput  auriculare  M.  styloglossi Graher)  is  sometimes 
found  as  an  independent  muscle,  the  stylo-auricular  is  of  Hyrtl  or  M. 
depressor  auriculce  of  Lauth.     The  muscle  just  mentioned  was  dis- 

'  Lehrbuch  der  systematischen  Anatomie  des  Menschen,  1873,  vol.  2,    p. 
759. 
'  Anatomie.  vol.  2,  p.  104. 


THE    EXTEKNAL    AUDITORY   CANAL.  11 

covered  by  Hyrtl,  and  is,  according  to  Huschke/  met  with  one  time 
ill  six;  it  is  fusiform,  and  from  one-half  to  one  and  one-half  lines  in 
thickness.  Both  these  muscles  appear  to  be  able  to  enlarge  and 
stretch  the  external  auditory  canal. 

The  platysma  myoides  or  M.  subcutaneous  colli  sends  also  occasion- 
ally some  lateral  fibres  to  the  under  surface  of  the  cartilage  of  the 
canal,  according  to  Cowper. 

The  skin  lining  the  canal  gradually  becomes  softer,  redder,  and 
more  vascular  and  sensitive,  more  secretory,  very  much  resembling  a 
mucous  membrane  as  it  covers  the  drum-head.  It  may  be  detached 
more  easily  from  the  canal  than  from  the  concha,  and  at  the  outer 
extremity  it  is  smoother.  Its  layers  grow  thinner  in  the  same  propor- 
tion; the  papillary  tissue  disappearing,  there  remains  at  the  mem- 
brana  tympani  scarcely  more  than  soft  and  thin  epidermis,  according 
to  Huschke. 

The  hairs  of  the  canal  are  shorter  and  finer  than  those  on  the 
tragus.  Usually  they  are  not  observed  before  the  age  of  puberty,  and 
in  some  individuals  are  much  more  abundant  than  in  others.  In  the 
bony  portion  of  the  canal  they  become  less  numerous  and  of  shorter 
length,  and  we  do  not  find  them  at  all  at  the  inner  end.  In  disordered 
states  of  the  meatus  these  hairs  fall  out  in  great  numbers.  Combin- 
ing with  the  increased  sebaceous  secretion  usually  present,  they  may 
constitute  a  part  of  ceruminous  collections. 

There  are  both  sebaceous  and  ceruminous  glands  in  the  external 
auditory  canal.  The  ceruminous  glands  are  found  in  greatest  num- 
bers at  the  junction  of  the  cartilaginous  and  bony  parts,  where  they 
may  number  twenty  to  thirty  to  the  square  line;  the  whole  number 
has  been  estimated  at  one  or  two  thousand.  These  glands  resemble 
somewhat  in  their  structure  the  sudorific  glands.  They  begin  with 
short  and  somewhat  straight  excretory  ducts  of  one-twentieth  to  one- 
fortieth  of  a  line  in  diameter,  the  glands  themselves  being  ovoidal  in 
shape  and  one-quarter  to  one-half  a  line  in  depth.  They  are  lodged 
in  a  rhomboidal  utricle  of  tendinous  tissue.  The  unequal  aspect  of 
the  glands  depends  on  the  turns  of  the  utricle  into  which  the  ten- 
dinous tissue  is  rolled.  Each  gland  terminates  in  a  dilated  extremity, 
and  is  lined  with  epithelial  scales. 

*  Splanchnologie,  p.  756. 


12  ATTACHMENT    OF    THE    AURICLE. 

THE  ATTACHMENT  OF  THE  AUKICLE  AND  CAETI- 
LAGINOUS  CANAL  TO  THE  TEMPORAL  BONE. 

The  cartilaginous  framework  of  the  ear  is  so  attached  to  the  tem- 
poral bone  as  to  admit  of  very  free  movement,  the  tubular  portion,, 
known  as  the  cartilaginous  canal,  being  loosely  telescoped,  so  to  speak, 
into  the  beveled  outer  surface  of  the  osseous  meatus,  and,  though, 
firmly  united  to  the  posterior  superior  curved  surface  of  the  auditory 
plate  (which  rounds  off  the  angle  formed  by  the  junction  of  the  pos- 
terior root  of  the  zygoma  with  the  mastoidea,  affording  a  long,  narrow, 
projecting,  and  roughened  articular  surface),  and  also  to  the  auditory 
process  of  the  tympanic  plate,  it  has  a  free,  gliding  motion  in  the 
surrounding  tissues. 

The  membranous  'portion,  which  has  been  described  as  closing  a 
large  defect  in  the  cartilage  composing  the  canal,  and  which  increases 
its  mobility,  is  attached  anteriorly  and  inferiorly  along  with  the  car- 
tilage to  that  portion  of  the  roughened  margin  of  the  osseous  meatus 
formed  by  the  auditory  process  of  the  tympanic  plate.  These  two 
osseous  margins,  affording  attachment  for  the  cartilaginous  canal,  run 
from  anteriorly  and  above  downwards  and  convergingly,  to  form  the 
ovoidal  opening  which  constitutes  the  osseous  meatus  auditorius  ex- 
ternus.  A  smooth  gap  is  left  between  the  beginning  of  these  rough 
margins  which  extends  all  the  loay  cloivn  along  the  anterior  wall  of  the 
osseous  meatus  to  the  smooth  outer  surface  of  the  auditory  plate;  over 
this  even  plane  glides  a  continuation  of  the  temporal  fascia,  the  sig- 
nificance of  which  will  be  considered  in  another  connection  (see  page 
22). 

The  common  integument  forming  the  outer  covering  of  the  auricle 
aids  somewhat  in  attaching  the  exterior  parts  to  the  deeper  ones,  but 
the  superficial  and  deep  layers  of  the  temporal  fascia  and  the  skin 
muscles  are  the  principal  means. 

Anteriorly  both  layers  of  fascia  give  off  fibrous  bands  which  are 
attached  to  and  blend  with  the  outer  face  of  the  cartilage  of  the  auri- 
cle. 1.  From  the  superficial  layer  to  the  anterior  superior  border; 
these  extend  themselves  to  the  posterior  edge  of  the  fossa  of  the  helix. 
2.  A  yet  stronger  band  from  the  deep  temporal  fascia  to  the  spine  of 
the  helix.  3.  A  strong  band  from  the  deep  fascia  is  attached  to  the 
tragus — a  superficial  portion  blending  with  the  cartilage,  and  a  deep 
portion  extending  along  the  cartilaginous  canal  to  its  attachment  to 
the  margin  of  the  osseous  meatus,  which  deep  connection  is  also  in- 
fluenced by  the  action  of  the  superficial  fascia. 


THE   AURIOULO-CRANIAL    MUSCLES.  13 

Posteriorly,  from  the  deep  fascia  a  band  is  attached  to  the  inner 
face  (convexity)  of  the  concha  just  above  the  insertion  of  the  scanty 
fibres  of  the  posterior  (retrahens)  muscle ;  another  band  passes  for- 
ward from  the  deep  fascia  about  the  anterior  border  of  the  mastoidea 
to  be  attached  a  little  below  the  former. 

The  auricle,  on  the  whole,  is  thus  attached  rather  loosely  to  the 
temporal  bone.  The  anterior  portion  of  the  inner  face  of  the  concha 
is  fixed  to  the  roughened  surface  of  the  mastoidea  by  the  fascia  and 
connective  tissue,  but  its  posterior  portion  is  free  and  can  be  felt  in  its 
place  over  the  mastoid  process. 

21ie  deep  cranial  aponeurosis,  which  is  thinner  over  the  temporal 
region  than  elsewhere,  lies  beneath  the  superior  and  anterior  auricu- 
lar and  the  superficial  temporal  muscles,  being  connected  to  them  by 
very  dense  cellular  tissue.  It  seems  to  bind  all  the  tensor  muscles, 
thus  giving  support  to  their  action.  When  acted  on  it  glides  freely 
over  the  deep  temporal  muscle.  It  sends  fibres  over  to  the  auricle  on 
a  level  with  the  tendon  of  the  superior  auricular  muscle,  after  crossing 
which  they  are  attached,  along  with  the  extrinsic  ligaments  of  the 
auricle,  to  the  convexity  of  the  concha. 

The  superficial  temporal  fascia  sends  fibres  of  attachment  to  the 
anterior  surface  of  the  tragus  and  to  the  spine  of  the  helix.  The 
deep  fascia,  blending  in  front  of  the  tragus  with  the  fibres  of  the 
above,  forms  a  strong  band  which  is  attached  along  the  outer  surface 
of  the  cartilage  of  the  canal  as  far  as  its  insertion  into  the  osseous 
meatus.  This  strong  band  lies  on  the  smooth  shallow  groove  formed 
upon  that  portion  of  the  squamosa  lying  between  the  tympanic  and 
auditory  plates  above  mentioned.  In  viewing  the  osseous  canal  in 
the  prepared  specimen  it  will  be  seen  that  its  roof,  formed  by  the 
auditory  plate,  extends  outwardly  much  further  than  the  floor  and 
sides,  which  are  formed  by  the  tympanic  plate  and  extend  inwardly 
(Leidy). 

THE   AUKICULO-CEANIAL  MUSCLES. 

The  Musculus  epicranius  is  considered  by  Henle  under  five  di- 
visions: 

M.  Epicr.  frontalis. 

M.  Epicr.  temporalis  (auricularis  anterior). 

M.  (Epicr.)  auricularis  superror. 

M.  (Epicr.)  auricularis  posterior. 

M.  Epicr.  occipitalis. 

These  small  thin  muscles  are  known  as  the  skin  muscles  of  the 


14 


THE    AIJRICULO-CKANIAL   MUSCLES. 


scalp,  and  from  them  such  motion  as  the  auricle  in  man  possesses 
is  derived.  This  may  once  have  been  greater  than  now,  hut  so  far 
as  the  needs  of  man  are  concerned  they  are  relatively  as  important 
as  those  in  some  of  the  lower  animals  where  they  still  possess  a  wide 
range  of  action,  as  may  he  seen  in  the  dog,  horse,  or  cat.  Their  ap- 
parent deterioration  may  be  due  to  disuse.  So  little  attention  has  been 
given  to  their  relations  to  the  movements  of  the  ear,  and  remotely 


Fig.  7.  —Muscles  of  the    Chanr-m  (from  Henle}. 

to  the  tension  of  the  transmitting  apparatus,  that  they  seem  entitled 
to  a  more  extensive  description  in  a  work  on  otology. 

Three  of  these  muscles  are  attached  directly  to  the  auricle :  (1) 
the  anterior  or  M.  epicranius  temporalis ;  (2)  the  superior ;  (3)  the 
posterior  auricularis.  Sappey  describes  a  fourth,  the  superficial  tem- 
poral, which  is,  however,  so  small  that  its  existence  has  been  doubted. 
It  takes  its  origin  from  the  temporal  fascia  and  is  attached  by  two 
fibrous  bundles,  of  which  the  superior  blends  with  the  occipito-fron- 
talis,  the  inferior  with  the  anterior  auricularis. 

The  anterior  auricular  s.  attrahens  auriculm  (or,  as  Henle  calls  it, 
the  M.  Epicranius  temporalis),  situated  on  the  lowest  part  of  the 
temple  in  front  of  the  auricle,  is  very  small,  extremely  thin,  and 
quadrilateral  in  form.     It  is  inserted  at  its  auricular  extremity  into 


THE    AURICULO-CRANIAL    MUSCLES. 


15 


the  projecting  spine  of  the  helix  and  the  corresponding  part  of  the 
anterior  edge  of  the  concha.  From  this  double  origin  it  passes  for- 
ward and  slightly  upward  and  is  inserted,  like  the  preceding,  upon 
the  cranial  fascia.  Sappey  says  the  greater  number  of  anatomists 
since  Winslow  have  erroneously  stated  that  this  '  muscle  has  a 
fixed  insertion  to  the  zygomatic  arch  ;  he  himself  has  always  found 
it  separated  from  the  latter  by  about  one  centimetre  and  forming  an 


Fig.  8.— Muscles  of  the  Head  (from  Sappey). 
1,  Posterior  auricular  muscle,  composed  of  two  bundles;  the  superior  short,  the  inferior 
longer;  2,  superior  auricular  muscle;  3,  anterior  auricular  muscle;  4,  occipital  muscle;  5, 
section  of  the  fascia  which  extends  from  the  external  third  of  the  occipital  muscle  to  the 
superior  occipital  muscle;  6,  fascia  starting  from  same  external  third  of  occipital  muscle 
which  passes  under  the  deep  face  of  the  superior  am-icular  muscle ;  7,  sujjerior  fibres  of 
superficial  temporal  [muscle,  situated  upon  the  prolongation  of  the  two  layers  arising  from 
the  occipital  muscle  ;  8,  inferior  fibres  of  same  united  to  the  anterior  auricular  by  the  inter- 
mediation of  a  fibrous  layer  which  forms  a  part  of  the  epicranial  fascia. 


acute  angle  with  it.  The  length  of  the  little  muscle  is  not  more  than 
twelve  to  fourteen  millimetres,  and  its  width  is  about  one  centimetre. 
It  lies  beneath  the  superficial  temporal  vessels  and  the  skin,  and  on  a 
plane  deeper  than  that  of  the  superior  auricular.     Immediately  be- 


16  THE    AURICULO-CBANIAL   MUSCLES. 

neath  it  is  the  cranial  fascia,  which  terminates  on  the  limits  of  the 
anterior  auricular,  blending  with  the  aponeurosis  of  the  crotophite 
(temporal)  muscle.  Its  lower  edge  runs  along  the  anterior  ligament 
of  the  auricle  which  covers  it  somewhat.  Its  superior  edge  is  con- 
tinued in  part  with  the  corresponding  edge  of  the  M.  elevator.  The 
use  of  this  muscle  is  to  draw  the  auricle  upwards  and  forwards.  It 
assists,  furthermore,  in  making  the  fascia  tense  (Sappey). 

According  to  Ilenle,  the  anterior  auricular  muscle,  or  muse,  epicr. 
temporalis,  i.  e.,  the  anterior,  narrow,  and  thin  strip  of  the  lateral 
portion  of  the  epicranius  muscle,  takes  its  tendinous  origin  beneath 
the  root  of  the  zygomatic  arch  on  the  margin  of  the  bony  canal.  It 
is  also  connected  with  the  cartilaginous  canal,  with  the  capsule  of  the 
temporo-maxillary  articulation,  and  with  a  tendon  under  which  the 
temporal  vessels  pass.  The  muscular  fibres  run  parallel  upwards  and 
forwards,  some  reaching  the  edge  of  the  epicranius  frontalis  and  the 
orbicularis  oculi. 

The  superior  auricular  (or  attolens  auricttlce)  is  the  most  impor- 
tant of  the  three  muscles  attached  to  the  auricle,  as  regards  size.  It 
is  situated  immediately  above  the  auricle  on  the  hinder  part  of  the 
temple;  it  is  vertical,  broad,  and  thin,  triangular  in  form,  the  trun- 
cated summit  presenting  downwards  to  be  inserted  on  the  convexity 
of  the  anti-helix,  and  also  on  the  corresponding  part  of  the  helix,  by 
the  aid  of  a  fibrous  lamella  of  a  gray  color. 

This  muscle  is  covered  externally  by  a  very  thin  aponeurotic  layer 
and.  by  the  skin.  It  lies  internally  throughout  on  the  cranial  apo- 
neurosis, which  envelops  the  entire  posterior  surface  of  the  auricle, 
and  is  lost  in  the  superior  attachment  of  the  muscle.  Its  posterior 
border,  ascending  vertically,  runs  along  the  superior  border  of  the 
occipital  muscle;  the  anterior  border  corresponds  inferiorly  to  the 
anterior  auricular  muscle  with  which  it  continues  in  part,  and  supe- 
riorly to  the  superficial  temporal  muscle  from  which  a  fibrous  inter- 
ception separates  it. 

The  uses  of  this  muscle  are  to  elevate  the  auricle  and  to  dilate  the 
external  auditory  meatus.  Its  action  also  aids  in  making  tense  the 
cranial  aponeurosis. 

T\iQ  posterior  auricular  {or  retrahens  auriciilm)  is  formed  usually 
of  two  small  bundles  of  muscular  fibres,  the  superior  and  the  inferior; 
rarely  they  are  united,  and  more  rarely  still  is  one  of  them  divided 
into  two.  These  bundles  extend  horizontally  from  the  auricle  to  the 
mastoid  process,  the  lower  one  extending  sometimes  even  to  the 
occipital  muscle;  they  are  attached  to  the  convexity  of  the  concha, 
pass  parallel  to  each  other,  backwards  and  slightly  upwards,  to  be 


THE    AUklCULOCRANlAL    MUSCLES.  17 

inserted,  the  superior  to  the  mastoid  process,  the  lower  sometimes  to 
the  same  place,  but  more  often  to  the  aponeurosis  at  the  insertion  of 
the  sterno-mastoid  muscle.  This  second  bundle  presents  frequent 
varieties;  sometimes  it  is  short  and  attached  immediately  under  the 
foregoing;  in  other  instances  it  is  longer,  Sappey  liaving  seen  it  pro- 
longed even  to  the  tendon  of  the  trapezius,  and  consisting  of  two 
distinct  bundles  united  by  a  large  fibrous  intersection,  one  of  which 
connected  with  its  origin,  the  other  with  its  termination.  The 
strength  of  these  tendons  indicates  the  very  considerable  potency  of 
this  muscle.  Superficially,  this  muscle  is  closely  connected  with  the 
skin  by  means  of  the  connective  tissue,  which  increases  in  thickness 
as  it  approaches  its  occipital  termination.  Its  action  is  to  draw  the 
auricle  backwards  and  dilate  the  external  auditory  meatus. 

The  above-mentioned  muscles  are  in  some  of  their  actions  aided 
considerably  by  the  occipito-frontaUs  muscle.  This  latter  really  con- 
sists of  four  muscles,  two  on  each  side;  the  two  of  the  same  side 
correspond — one  of  them,  the  occipital,  to  the  posterior  part  of  the 
cranium,  the  other,  the  frontal,  to  its  anterior  part.  Being  united 
by  the  cranial  aponeurosis,  they  have  been  considered  as  a  digastric 
muscle,  to  which  has  been  given  the  name  of  occipito-frontalis. 

The  occipital  muscle  {epicrmiius  occipitalis)  blends  with  the  mas- 
toideus  and  trapezius  muscles  (see  cut).  From  its  external  third 
starts  a  fibrous  band  which  divides  itself  on  a  level  with  the  superior 
auricular  muscle  into  two  layers,  one  of  which  covers  the  cutaneous 
face  of  this  muscle,  while  the  other  passes  beneath  it  and  towards  the 
superficial  temporal  muscle.  The  anterior  edge  of  the  muscle  is 
almost  horizontal,  and  presents  to  the  mastoid  portion  of  the  tempo- 
ral bone  and  to  the  tendon  of  the  superior  auricular  muscle.  Its 
upper  edge  corresponds  to  the  posterior  edge  of  the  superior  auricu- 
lar, so  that  the  fibres  of  the  two  muscles  are  both  perpendicular. 

The  principal  use  of  this  muscle  is  to  draw  the  cranial  aponeurosis 
downward  and  backward  and  thus  assist  the  action  of  the  frontalis, 
since  the  one  muscle  affords  the  fulcrum  on  which  the  other  acts. 

The  frontal  muscles  have  been  considered  by  a  large  number  of 
authors  as  forming  a  single  muscle,  but  clinical  observation  and 
electro-physiological  experiments  establish  clearly  that  they  are  inde- 
pendent. The  frontalis  arises  from  the  anterior  part  of  the  facial 
aponeurosis  by  two  origins  a  little  in  front  of  the  frontal-parietal 
suture,  and  descends — the  internal  fibres  passing  vertically,  the  others 
obliquely — to  be  inserted  along  with  the  orbicular  into  the  skin  of  the 
eyebrows. 
The  writer  has  seen  instances  where  the  occipital  and  temporal 
2 


IS  TEMPOKO-MAXILLARY    ARTICULATION. 

muscles,  acting  independently  of  each  other,  exerted  an  influence  on 
the  fascia  in  such  a  manner  as  to  very  much  assist  the  aural  muscles 
in  moving  the  ear. 

For  the  anatomical  description  of  these  muscles  and  the  neighbor- 
ing fascia,  the  writer,  besides  his  own  limited  dissections,  is  indebted 
to  the  works  of  other  writers,  notably  those  of  Henle  and  Sappey. 

Further  research  in  the  comparative  anatomy  of  this  subject  is 
much  needed,  since  from  this  source  alone  can  many  disputed  and 
obscure  points  in  the  functions  of  the  ear  be  settled. 

JRELATIONS    OF    THE     TEMPORO-MAXILLARY    ARTICU- 
LATION TO  THE  CARTILAGINOUS  PORTION  OF 
THE  EXTERNAL  AUDITORY  CANAL. 

The  parietes  of  the  cartilaginous  portion  of  the  external  auditory 
canal  are  compressed  from  before  backwards  by  the  condyle  of  the 
lower  jaw  in  front.  The  movement  of  the  condyle  against  the  anterior 
face  of  the  yielding  canal  may  be  felt  on  placing  the  finger  in  the 
concha  during  mastication;  it  brings  the  anterior  wall  of  the  canal 
into  varying  relations  with  the  mastoidea,  against  which  the  posterior 
wall  lies  separated  only  by  connective  tissue  and  fat. 

Whilst  admitting  of  this  encroachment  of  the  condyle,  it  also 
readily  partakes  of  the  free  movements  of  the  auricle. 

The  canal  glides  freely  up  and  down  the  space  between  the  ramus 
of  the  jaw  and  mastoidea,  which  also  afford  it  protection. 

The  well-known  change  which  the  lower  jaw  undergoes  with  in- 
creasing years  is  often  very  marked.  The  ramus,  almost  vertical  in 
adolescence,  and  joining  the  body  of  the  bone  at  a  right  angle,  becomes 
afterwards  reduced  in  size,  more  oblique,  and  the  angle  obtuse;  where 
early  loss  of  the  molar  teeth  has  occurred,  this  takes  place  sooner. 
Under  this  change,  the  jaw  has  a  very  much  increased  range  of 
motion  sometimes,  the  acts  of  opening  the  mouth  widely,  as  in  masti- 
cation and  yawning,  causing  the  anterior  wall  of  the  concha,  just 
below  the  tragus,  to  be  drawn  downwards  and  forwards,  as  the  con- 
dyle rides  forwards.  Naturally,  the  condyle  is  always  carried  forward 
about  one  centimetre  in  opening  the  jaws,  while  the  fibro-cartilage  is 
also  displaced,  but  in  an  opposite  direction;  in  the  words  of  Sappey, 
*'  the  condyle  slides  on  the  fibro-cartilage  of  the  glenoid  fossa  from 
behind  forwards,  while  the  fibro-cartilage  slides  on  the  condyle  from 
before  backwards."  Distressing  acoustic  phenomena  are  common  in 
subjects  having  this  undue  range  of  motion  in  the  temporo-maxillary 
articulation  and  where  anomalies  also  exist  in  the  drum's  tension,  the 


TEMPOKO-MAXILLAEY    ARTICULATION.  19 

effort  of  yawning  under  these  conditions  putting  the  drum-head  un- 
duly upon  the  stretch.  The  act  of  yawning  also  causes,  through 
contraction  of  the  tensor  muscles  of  the  palate,  tension  upon  the  ham- 
mer through  the  tensor  tympani.  The  rapid  variations  in  auditory 
tension,  both  from  without  and  from  within,  give  rise  to  autophonia 
and  other  symptoms. 

The  following  cases  are  illustrative  of  the  above: 

Case  I. — Male,  51  years  of  age,  of  large  osseous  and  muscular 
development,  but  thin.  Motion  of  temporo-maxillary  articulation 
during  movements  of  jaw  can  be  plainly  seen  on  looking  into  the 
■concha.  With  each  movement  the  lumen  of  the  aerial  conduit  is 
almost  obliterated,  the  condyle  becomes  very  prominent  in  front  of 
the  tragus,  which  is  bent  forwards  upon  itself,  and  the  auricle  is  made 
to  rotate  anteriorly  upon  its  axis.  If  the  finger  be  placed  in  the  meatus, 
which  is  large  enough  to  admit  its  end,  it  will  be  very  decidedly 
squeezed  when  the  jaws  are  widely  opened.  The  drum-heads,  un- 
usually large  and  relaxed,  show  the  presence  of  trophic  changes.  The 
patient  always  experiences  dizziness,  and  is  usually  nauseated  from 
masticating  his  food — phenomena  due  to  variations  of  drum  tension. 
Occasionally  the  vertiginous  condition  comes  on  at  other  times, 
entirely  preventing  locomotion.  There  is  constant  autophonia  and 
a  feeling  of  confusing  numbness  about  the  ear.  When  moderate 
traction  on  the  auricle  is  maintained,  this  symptom  is  relieved,  and 
hearing  is  improved.  These  experiences  have  finally  made  the  pa- 
tient exceedingly  nervous,  and  he  is  no  longer  able  to  attend  to  his 
business.  He  has  been  treated  by  many  physicians,  one  of  whom  re- 
garded his  trouble  as  gastric. 

Ca^e  II. — Male,  21  years  of  age,  a  subject  of  chronic  aural  catarrh, 
the  drum-heads  being  greatly  relaxed.  The  temporo-maxillary 
articulations  admit  of  unusually  free  motion  of  the  lower  jaw,  even 
moderate  separation  is  attended  with  lateral  displacement.  This  is 
most  marked  on  the  right  side,  where  the  coronoid  process  can  be.  felt 
to  impinge  very  much  on  the  cartilaginous  canal,  if  the  finger  be 
placed  in  the  right  concha;  the  movement  may  be  observed  also  by  the 
the  eye.  Patient  is  subject  to  exacerbations  of  head  catarrh  when  the 
autophonia  is  much  more  marked,  especially  on  the  right  side.  Tem- 
porary relief  follows  voluntary  sub-luxation  of  the  lower  jaw,  short 
but  vigorous  efforts  of  expelling  air  from  the  nose,  slight  inflation  by 
the  Valsalvan  experiment,  or  traction  upon  the  concha,  all  of  which 
may  be  made  to  restore  the  drum  tension.  The  large  size  of  the  canals 
and  drum-heads  permits  easy  inspection  of  the  latter,  which,  during 
inflation,  are  greatly  relaxed;  they  may  be  seen  to  move  in  and  out 
during  intra-tympanic  inflation  and  rarefaction.  The  shock  from  the 
inflation  occurring  on  blowing  the  nose  once  gave  r;se  to  vertigo  and 
falling  to  the  ground.  It  is  notable  that,  while  moderate  inflation 
improves  the  hearing,  decided  inflation  forces  the  drum-heads  out  too 
far  and  increases  the  deafness. 

Baron  D.  J.  Larrey,  in   ^^Observations  on  Wounds,"  etc.,'  alludes 
'  Ed.  1832,  Philadelphia,  page  254. 


20  REMARKS    ON    THE    EXTERIOR   MUSCLES. 

to  the  encroachment  of  the  condyle  of  the  lower  jaw  upon  the  canal  as 
a  cause  of  deafness,  alleging  that  this  result  is  due  to  obliteration  of 
the  walls  of  the  canal,  whereby  ''the  rays  of  sound  can  no  longer 
reach  the  tympanum/'  That  the  closure  of  the  canal  interferes  with 
the  entrance  of  sound  is  doubtlessly  true;  but  the  principal  cause  of 
deafness  in  these  cases  is  interference  with  the  tension  of  the  trans- 
mitting mechanism. 

In  inflammation  of  the  external  auditory  canal,  and  of  the  middle 
ear,  mastication  is  often  attended  with  much  pain. 

FURTHER  REMARKS   ON  THE   EXTERIOR   MUSCLES 
AND   FASCIA   OF   THE   EAR. 

The  exterior  muscles  are  but  seldom  under  the  voluntary  control  of 
man  to  the  same  extent  witnessed  in  lower  animals,  but,  as  will  be 
seen  in  another  part  of  this  work  (p.  30),  numerous  cases  occur 
where  the  voluntary  control  of  these  muscles  is  present  in  a  remark- 
able degree.  The  writer  is  convinced  from  his  own  observations  that, 
acting  voluntarily,  these  muscles  are  of  the  greatest  importance. 
Most  persons,  however,  possess  the  ability  to  voluntarily  make  tense 
the  membrana  flaccida  through  contractions  of  the  superficial 
muscles,  the  act  being  doubtlessly  attended  with  the  unconscious 
performance  of  several  functional  movements  connected  with  the 
modus  operandi  of  audition ;  thus  the  M.  incisurae  Santorini,  to- 
gether with  the  auricular  styloid  muscle  (p.  11),  when  in  action, 
enlarge  and  stretch  the  cartilaginous  canal,  and  it  would  seem  even 
possible  for  the  canal  to  be  further  acted  upon  by  so  remote  a 
muscle  as  the  styloglossus,  whose  special  function  it  is  to  draw  the 
tongue  upwards  and  backwards. 

The  posterior  auricular  muscle  is  frequently  found  sending  fibres 
of  insertion  to  the  sterno-mastoid  and  trapezius  muscles.  When 
acting  in  conjunction  with  these  muscles,  the  effect  would  be  to  very 
much  increase  its  power  of  drawing  the  auricle  backward  and  of 
dilating  the  external  auditory  meatus. 

The  frequent  anomalous  development  of  the  exterior  aural  muscles 
in  man,  when  contrasted  with  the  constant  existence  of  more  efficient 
muscles  in  the  lower  forms  of  animal  life,  enables  us  to  form  a  better 
idea  of  their  functions  in  the  former. 

This  entire  group  of  muscles  then  may  be  regarded  as  having  no 
other  use  than  acting  upon  and  regulating  in  various  ways  the  move- 
ments of  the  auricle  and  external  auditory  canal.  Some  of  the  move- 
ments of  the  auricle  are  of  interest  here.     Thus,  in  persons  having 


BEMAKKS    ON    THE    EXTERIOR    MUSCLES.  21 

the  power  to  voluntarily  move  the  crauial  aponeurosis  freely,  the 
temporal  muscle  may  be  seen  during  mastication  to  bring  into  action 
both  the  superior  and  anterior  auricular  muscles,  the  auricle  often 
being  elevated  as  much  as  a  quarter  of  an  inch  with  each  contraction 
of  the  superior  auricularis. 

Many  individuals  are  able  to  draw  the  auricle  backwards,  but 
much  more  frequently  forwards  and  upwards.  While  it  is  true  that 
the  integumentary  lining,  including  the  skin,  of  the  exterior  out- 
let maintains  the  normal  state  of  tension  in  the  drum-head,  the 
fascia  of  the  anterior  wall,  to  which  the  tendon  of  the  anterior  auri- 
cular is  attached  at  the  outlet  of  the  osseous  canal,  responds  to  con- 
tractions of  the  latter  muscle  and  its  auxiliaries,  the  frontalis  and 
orbicularis,  through  which  the  tension  of  the  membrana  flaccida  is 
increased. 

The  consequences  of  impairment  of  tympanic  tension  through  re- 
laxation of  the  exterior  parts  are  mentioned  elsewhere;  the  swelling  of 
these  parts  from  inflammation  also  has  its  significance,  such  changes 
giving  rise  to  phenomena  which,  if  rightly  interpreted,  may  aid  very 
much  in  forming  a  diagnosis  from  symptoms  otherwise  perplexing. 
Autophouia  is  common  to  diseases  affecting  both  the  exteraal  and 
middle  ear,  yet  often  differs  sufficiently  to  very  much  facilitate 
making  a  differential  diagnosis. 

The  movements  consequent  on  voluntary  action  of  the  exterior 
aural  muscles  are  perceptible  to  both  sight  and  touch,  and  the  same 
may  be  said  of  their  unconscious  action;  thus  the  arrectus  auris  or 
auricularis  superior  may  often  be  observed  in  persons  when  intently 
listening,  the  auricle  being  gradually  raised,  though  not  always 
appearing  to  be  out  of  place  until  relaxation  occurs,  when  it  may  be 
seen  to  suddenly  gravitate  down  to  its  usual  position  in  repose. 

In  order  to  demonstrate  the  motion  of  the  exterior  muscles,  espe- 
cially that  of  the  anterior  auricular,  as  transmitted  through  their 
tendinous  connections  with  the  membrana  flaccida,  the  writer,  assisted 
by  Dr.  S.  H.  Pinkerton,  made  a  dissection  of  these  parts  in  a  recent 
subject. 

First  the  deep  temporal  fascia  was  dissected  up  to  where  it  is  blended 
with  the  anterior  ligament  of  the  auricle.  At  this  stage  of  the  pro- 
ceeding, it  was  found  that  traction  on  the  deep  temporal  fascia  moved 
the  auricle  freely.  The  anterior  attachment  of  the  auricle  was  then 
divided,  and  a  section  of  the  petrous  bone  was  made  by  sawing  down 
through  the  typanum  from  above,  separating  the  incus  from  the 
stapes  and  bisecting  the  tensor  tympani  muscle  in  its  bony  canal, 
leaving  the  rest  of  the  mechanism  of  the  middle  ear  intact,  with  the 


22  REMARKS    ON    THE    EXTERIOR    MUSCLES. 

exception  of  a  slight  laceration  of  the  drum-head  at  its  inferior  seg- 
ment. It  was  now  found  that  if  that  portion  of  the  tensor  tympani 
left  attached  to  the  manubrium  mallei  was  made  taut  and  so  retained 
in  the  grasp  of  forceps  while  traction  was  made  as  before  on  the  tem- 
poral fascia,  which  had  been  dissected  up,  the  transmitting  mechanism 
responded  promptly  and  became  more  tense  than  before.  When 
alternate  tension  and  relaxation  was  practised  on  the  fascia,  the 
drum-head  tightened  and  relaxed  likewise,  the  motion  being  per- 
ceptible to  the  eye.  These  apparently  demonstrable  influences  of 
muscular  action  in  the  middle  ear  mechanism  in  man  are  similar  to 
those  which,  in  a  more  perfect  manner,  are  probably  obtained  in  the 
horse,  dog,  and  other  animals  by  means  of  the  voluntary  action  of 
their  more  efficient  muscles. 

A  knowledge  of  the  significance  of  the  relations  between  the 
exterior  parts  of  the  ear  and  the  middle  ear  mechanism  which  the 
author  has  attempted  to  outline,  enables  us  to  account  for  some  of 
the  phenomena  produced  by  alterations  in  the  tension  of  the  trans- 
mitting apparatus,  whereby  the  normal  equilibrium  is  altered.  Thus, 
the  membrana  tympani  may  have  its  tension  very  much  disturbed  by 
alterations  in  the  tone  of  the  cutaneous  lining  of  the  ear,  or  of 
the  fascia  and  muscles  connected  with  it.  An  explanation  may  thus 
be  found  for  the  variation  in  hearing  experienced  by  persons  who 
alternately  pass  their  time  in  the  cold  bracing  out-door  air,  and  in 
warm  apartments;  the  toning-up  effects  of  the  former  improving 
hearing,  while  relaxation  and  dulness  of  hearing  occurs  from  atmo- 
spheric humidity  or  in-door  warmth. 

The  cartilage  of  the  canal  and  pinna  are  frequently  found  collapsed 
in  old  age.  The  lumen  of  the  canal  becomes  thus  almost  obliterated, 
the  inner  wall  of  the  concha  falling  over  the  opening  of  the  meatus. 
and,  from  loss  of  tone  in  the  skin,  fascia  and  muscular  structure  as 
well  as  in  the  cartilage,  the  entire  exterior  ear  drops  down  from  want 
of  its  natural  support,  leaving  the  skin  in  front  of  the  tragus,  and 
sometimes  behind  the  auricle,  deeply  wrinkled.  It  is  probable  that 
this  relaxation  is  accompanied  with  a  certain  amount  of  compensatory 
tension  due  to  the  more  dependent  position  of  the  auricle  ;  it  will  be 
found,  however,  very  soon  that  lifting  the  auricle  upwards,  back- 
wards, and  outwards  or  pushing  it  downwards  by  placing  the  finger 
in  the  concha,  is  necessary  to  clear  up  the  dulness  of  hearing  occur- 
ring in  many  of  these  cases. 

In  practice  one  constantly  meets  with  disturbances  of  tension  in 
both  chronic  and  acute  catarrhal  inflammation  of  the  middle  ear, 
both  purulent  and  non-purulent;  furthermore,  in  cases  where  a  mano- 


REMARKS    ON    THE    EXTERIOR    MUSCLES.  23 

metric  membrane  exists,  in  inflammation  of  the  external  auditory- 
canal,  and  where  ceruminoiis  collections  become  impacted.  The 
following  are  cases  where  relaxation  has  occurred  consequent  upon 
chronic  catarrhal  inflammation  of  the  middle  ear. 

Case  1. — Male,  42  years  of  age.  Fifteen  years  ago  contracted 
syphilis,  since  which  both  nasal  and  aural  catarrh  has  become  severe, 
and  deafness  very  decided.  Owing  to  alterations  in  the  transmitting 
mechanism,  excursions  of  the  membrana  tympani  have  been  at- 
tended with  sensations  of  the  ear  being  alternately  opened  and 
closed  "  like  a  door."  The  autophonous  phenomena,  which  are  very 
distressing,  are  relieved  tuhen  the  patient  turns  the  affected  ear  down- 
ivards;  returning  again  ivhen  the  organ  is  tnrjiedupivards.  Relief  is 
obtained  also  by  pulling  the  auricle  outwards  ivhenever  autophonia  is 
present. 

Case  2. — Female,  43  years  of  age.  Long-standing  chronic  catarrhal 
inflammation  of  both  drums  ;  autophonia  and  deafness  most  marked 
in  the  right  ear,  symptoms  which  are  relieved  by  traction  made  by 
placing  end  of  finger  in  the  concha. 

Case  3. — Male,  47  years  of  age.  Catarrhal  inflammation  of  drums 
of  long  standing.  For  the  relief  of  deafness  of  right  ear  the  patient 
has  the  habit  of  pulling  out  and  shaking  the  auricle. 

Case  4. — Male,  40  years  of  age.  The  long-standing  chronic  catar- 
rhal inflammation  of  drums  is  accompanied  by  autophonia  in  the  right 
ear.  An  exostosis  on  the  posterior  wall  of  the  right  external  audi- 
tory canal  near  the  drum-head  seems  to  increase  the  trouble.  For 
past  week  the  right  ear  has  a  feeling  of  being  "  stuffed  with  wool.'* 
Patient  has  long  had  the  habit  of  easing  the  "stopped  up"  feeling  in 
right  ear  by  placing  the  forefinger  in  the  concha  and  drawing  the 
parts  outwardly. 

Case  5. — Male,  35  years  of  age.  Very  great  deafness  due  to  chronic 
catarrhal  inflammation  of  the  drums.  The  skin  about  the  auricle  is 
relaxed  and  wrinkled.  Has  the  habit  of  shaking  auricle  to  ''clear 
the  hearing."  Experiments  showed  that  when  the  outer  parts  were 
put  on  the  stretch,  high  notes  could  be  heard  much  better. 

Case  6. — Male,  63  years  of  age.  Has  long  had  chronic  catarrh  of 
the  drums  and  the  drum-heads  show  trophic  changes.  For  a  long 
time  slightly  deaf,  but  since  attack  of  typhoid  fever  one  year  ago  the 
hearing  is  so  much  worse  that  he  cannot  carry  on  ordinary  conversa- 
tion. The  occasional  autophonia  is  very  distressing.  He  relieves  this 
and  also  improves  hearing  by  making  traction  on  the  auricles  with 
the  fingers. 

Case  7. — Male,  50  years  of  age.  This  professional  singer  sings 
out  of  tune.  Has  chronic  nasal  and  aural  catarrh.  The  *'  ears 
close,"  and  gentle  traction  on  auricles  "opens"  them  again. 

Case  8. — Male,  51  years  of  age.     Has  parchment-like  drum-heads, 


24  REMARKS    ON   THE    EXTERIOR   MUSCLES. 

with  loss  of  tension  throughout  both  transmitting  mechanism  and 
the  outer  parts.  The  symptoms  of  autophonia  and  deafness  are 
sometimes  relieved  by  gentle  traction  ;  but  if  done  violently  the 
trouble  is  increased. 

Case  9. — Male,  55  years  of  age.  The  chronic  catarrhal  inflamma- 
tion of  the  middle  ear  gives  rise  to  dumb  feeling  in  the  ears  and 
autophonia,  both  symptoms  being  relieved  by  traction  on  the  auricles. 

Case  10. — Male,  40  years  of  age.  Long-standing  and  severe  nasal 
and  aural  catarrh  accompanied  by  great  deafness.  The  right  drum- 
head was  once  ruptured  by  a  blow  on  the  ear  ;  it  seemed  to  increase 
the  defectiveness  of  the  transmitting  mechanism.  Hearing  is  im- 
proved by  pressing  auricle  forward  with  the  open  hand  until  folded 
upon  itself.  The  improvement  was  notable  both  for  the  watch  and 
voice. 

The  following  are  cases  where  auditory  tension  was  affected  by 
acute  inflammation  of  the  middle  ear  : 

Case  11. — Male,  53  years  of  age.  A  cornet  player.  Since  attack  of 
a,cute  aural  catarrh  a  few  days  ago  the  voice  and  cornet  sound  auto- 
phonously  in  the  left  ear.  These  phenomena  disappear  on  making 
traction  on  auricle. 

Case  12. — Male,  51  years  of  age.  An  attack  of  acute  purulent  in- 
flammation of  the  middle  ear  gave  rise  to  autophonia  and  very  dis- 
agreeable rumbling  sounds  in  one  ear  ;  both  were  stopped  by  gently 
drawing  upon  the  auricle. 

Cases  where  chronic  purulent  inflammation  gave  rise  to  altered 
tension. 

Case  13.— Male,  14  years  of  age.  Left  ear  has  been  running  for 
six  years.  Has  long  had  the  habit  of  pulling  the  auricle  of  the 
affected  ear  to  "'clear  the  hearing." 

Case  14. — Male,  23  years  old.  Has  had  since  infancy  purulent 
inflammation  of  the  right  tympanum,  especially  of  the  attic,  with 
deafness  for  low  sounds.  He  can  voluntarily  move  the  auricles  back- 
wards very  freely,  the  right  most,  from  practice  perhaps  in  his  efforts 
to  hear.  Hears  both  voice  and  watch  better  when  ear  is  voluntarily- 
elevated.     Hears  best  in  a  noise. 

Case  15. — Male,  34  years  old.  One  ear  has  long  discharged  and  is 
the  seat  of  much  tinnitus  which  is  stopped  by  drawing  out  the 
auricle. 

Case  16. — Female,  47  years  of  age.  Ears  have  been  running  for 
many  years.  Deafness  much  increased  by  pushing  in  the  auricles, 
and  is  improved  by  pulling  them  out. 

Case  17. — Female,  25  years  old.     The  deafness  and  autophonia. 


BEMARKS   ON   THE    EXTERIOR    MUSCLES.  25 

due  in  this  case  to  chronic  purulent  inflammation  ot  the  middle 
ear,  was  improved  by  lifting  the  concha  upwards  and  backwards. 

Case  where  auditory  tension  was  affected  by  large  perforation. 

Case  18. — Male,  31  years  of  age.  The  left  membrana  tynipani 
has  a  large  perforation.  There  is  no  discharge.  Voice  sounds  caver- 
nous in  the  ear,  "seems  to  come  from  a  barrel."  Drawing  left  auricle 
forward  with  open. hand  relieves  this  entirely. 

Case  where  auditory  tension  was  disturbed  by  a  manometric  resto- 
ration. 

Case  19. — Female,  33  years  of  age.  Hears  best  in  a  noise.  Watch 
heard  best  when  auricle  is  drawn  outwardly. 

Case  where  the  membrana  tympaui  was  almost  entirely  absent. 

Case  20. — Male,  42  years  of  age.  The  membrana  tympani  has 
long  been  very  nearly  entirely  absent,  the  membrana  flaccida  and 
chain  of  ossicles  remaining  in  a  defective  state.  There  is  of  course 
an  entire  absence  of  equilibrium  in  the  transmitting  mechanism,  and 
the  hearing  varies  in  the  most  eccentric  manner.  Good  hearing  can 
be  temporarily  brought  about  if  the  membrana  flaccida  be  made 
tense  by  traction  on  the  auricle. 

Cases  where  the  auditory  tension  was  disturbed  by  desquamative 
inflammation  of  the  external  auditory  canal  and  by  the  impaction  of 
cerumen. 

Case  21. — Male,  59  years  of  age.  Has  desquamative  inflammation 
of  the  external  auditory  canal  with  seborrhcea.  When  an  accumula- 
tion has  formed,  the  ear  becomes  very  uncomfortable  from  its  ini- 
paction  against  the  drum-head  ;  relief  is  instantly  obtained  by  draw- 
ing the  auricle  outwardly  and  then  shaking  it,  thus  showing  the  pos- 
sibility of  carrying  the  mass  away  from  the  drum-head  upon  the 
moving  dermis  which  is  made  to  glide  over  the  bony  canal. 

Case  22. — Male,  51  years  of  age.  Collection  of  soft  cerumen  im- 
pacted in  left  ear,  causing  "numbness."  Relief  is  obtained  by 
making  traction  on  auricle. 

Case  23. — Male,  67  years  of  age.  Canals  are  collapsed  within 
lumen.  Has  considerable  deafness,  but  it  is  much  less  in  cold 
weather.  The  "cloudiness"  in  the  right  ear  is  removed  always  by 
placing  the  head  of  a  lead  pencil  in  the  canal  and  making  traction 
outwardly.  The  case  came  for  treatment  on  account  of  the  retention 
of  the  soft  rubber  head  of  a  pencil  in  the  ear. 

Case  24. — Male,  45  years  of  age.  Soft  wax  is  impacted  in  both 
■ears  against  the  drum-heads  ;  brought  about  by  a  fall  on  the  ice  six 
years  ago.  There  was  continual  deafness  for  a  few  months  after  the 
fall,' and  ever  since  occasional  impactions  accompanied  by  a  "crack 
like  a  cannon  shot."     On  giving  the  ear  a  "jerk,"  hearing  remains 


26  COMPARATIVE   PHYSIOLOGY    OF   THE   AUKICLE. 

good  for  half  an  hour.  On  getting  up  in  the  morning  he  cannot  hear 
at  all  until  he  puts  his  finger  into  the  conchas  and  gives  them  a  "  shak- 
ing up/'  when  he  hears  for  a  time. 

The  cases  just  given  have  been  selected  from  the  records  of  a  large 
number  of  similar  ones.  In  a  great  number  of  instances  the  writer 
has  been  told  by  patients  that  gentle  pressure  with  the  forefinger  upon 
the  lower  edge  of  the  concha  ** clears  up  their  hearing"  temporarily. 
The  act  is  very  often  unconsciously  practised  by  the  patients  when 
troubled  with  an  uncomfortable  feeling  in  the  ears,  due  to  disturb- 
ance of  equilibrium  in  the  transmitting  mechanism. 

In  one  instance,  a  patient,  20  years  of  age,  could  relieve  auto- 
phonous  symptoms  at  times  by  pressing  upon  the  tragus. 

OBSERVATIONS   ON   THE    COMPARATIVE    PHYSIOLOGY 
OF   THE  AURICLE. 

The  voluntary  ear  movements  of  some^of  the  more  common  forms  of 
animal  life  below  man  in  the  scale,  such  as  the  horse,  dog,  and  cat, 
are  very  remarkable,  the  ears  of  these  mammals  being  capable  of  per- 
forming an  almost  complete  revolution  upon  their  axis.  In  the  dog 
and  cat  the  auricular  cartilage  is  much  more  soft  and  flexible  than  in 
man,  and  the  skin  muscles,  though  delicate,  are  exceedingly  efficient. 
Accustomed  as  we  are  to  estimate  muscular  force  by  the  biceps  of  the 
blacksmith  or  athlete,  we  are  scarcely  prepared  to  reckon  the  power 
of  the  skin  muscles  which  lie  within  our  grasp  when  handling  the 
loose  hide  upon  animals,  that  of  the  dog,  in  particular,  whose  entire 
scalp  slides  freely  over  the  skull,  yet  with  what  energy  they  agitate 
the  skin  at  will!  The  auricle  in  these  quadrupeds,  which  is  so  loosely 
attached  to  the  head,  and  so  easily  compressed  when  in  close  quarters, 
is  very  effectively  employed  in  gathering  sound.  In  the  act  of  lis- 
tening, the  convexity  of  the  auricle  is  presented  in  different  directions 
until  the  source  is  discovered,  and  every  observer  is  familiar  with  the 
widely  expanded,  erect  auricle  of  animals  as  this  takes  place. 

Birds  having  no  outstanding  auricle  turn  the  head  rapidly  in  all 
directions  until  the  source  of  sound  is  discovered,  when  the  head  i& 
held  with  one  ear  cocked  up  in  the  direction  from  whence  it  comes. 

During  the  visit  at  the  country  residence  of  a  friend,  the  author 
availed  himself  of  the  opportunity  offered  to  examine  the  ears  of 
some  of  the  dogs  of  the  kennel.  It  was  found  in  setters  and  other 
dogs  where  a  strain  of  spaniel  prevails,  that  the  drooping  ears  seemed 
to  afford  a  natural  shield  to  the  deeper  and  more  delicate  parts  o^  the 
organ,  which  are  much  exposed  in  these  frequenters  of  the  water  and 


comparativp:  physiology  of  the  auricle.  27 

rovers  of  the  field.  The  cartilage  of  the  pinna,  however,  is  no  larger 
than  in  breeds  carrying  their  ears  erect,  being  absent  in  the  most 
pendent  part,  and  that  portion  composing  the  commencement  of  the 
external  auditory  canal  is  much  dilated,  forming  a  very  large  concha, 
which,  when  the  external  ear  is  in  repose,  contracts  into  folds  like 
the  mouth  of  a  purse,  thus  protecting  the  ear  from  the  entrance  of 
foreign  bodies,  etc.  When  the  pendent  portion  of  the  auricle  is 
lifted  up,  so  as  to  aiford  a  better  view  of  the  entrance  to  the  external 
auditory  canal,  there  are  to  be  seen  a  number  of  operculse,  formed 
from  the  outer  margin  of  the  collapsed  walls;  one  of  these,  larger 
than  the  rest,  seems  to  correspond  to  the  tragus  in  the  human  ear. 
When  the  animal  is  on  the  alert  in  listening,  the  drooping  auricle  is 
lifted  up  and  expanded,  and  the  pliant  cartilage  unfolded,  the  act 
being  performed  by  the  retrahens  aurem  and  attolens  aurem,  which 
muscles  together  lift  the  auricle  backward  and  upward  with  much 
energy,  thus  bringing  a  most  efficient  sound-collecting  trumpet  into 
use. 

The  hearing  is  possibly  further  improved  in  fielding  by  the  con- 
stant motion  of  the  dog's  head,  his  ears  being  thus  frequently  thrown 
up,  the  act  giving  greater  exposure  to  the  concha.  The  act  of  ex- 
panding the  auricle  would  seem  to  also  render  the  drum  head  more 
tense,  and,  on  the  other  hand,  the  dog  is  observed  to  droop  his  ears 
to  loud  and  disagreeable  sounds,  the  drum-head  being  probably  re- 
laxed in  this  way,  while,  at  the  same  time,  sound  is  more  completely 
excluded  by  the  collapse  of  the  cartilage  and  the  more  overlying  and 
pendent  auricle.  In  this  manner,  more  or  less  complete  muffling  of 
the  sound-transmitting  mechanism  takes  place,  without  which  the 
sensitive  hearing  organ  possessed  by  these  animals  would  be  liable  to 
injury  from  loud  sounds. 

A  gentleman,  a  close  observer  of  the  habits  of  animals,  who  came 
from  Ohio  to  consult  the  writer,  has  frequently  seen  a  young  spaniel 
in  his  possession  throw  up  its  ears  with  marvellous  quickness  on  hear- 
ing very  distant  sounds,  remaining  in  this  attitude  for  some  moments, 
as  though  straining  to  detect  their  source  and  nature.  He  also  has 
observed  that  during  a  thunder  storm  the  dog  would  droop  the  auri- 
cles, and  throw  back  his  head,  his  distress  from  the  painful  sounds 
being  manifested  by  every  act. 

The  same  gentleman  informs  the  author  that,  in  witnessing  the 
combats  between  cats,  he  has  been  struck  by  the  characteristic  posi- 
tion in  which  the  auricles  are  placed  when  the  enraged  felines  rush 
into  the  arena  to  begin  the  contest.  The  organ  is  drawn  firmly  back- 
wards and  somewhat  downwards,  out  of  harm's  M'.ay,  this  act  closing 


28  COMPAKATR'E    PHYSIOLOGY   OF   THE    AURICLE. 

the  entrance  to'the  ear.  While  both  animals  now  give  utterance  to 
the  most  distracting  noises,  each  seems  to  thus  exclude  the  cries  of 
the  other.  The  eyes  are  also  kept  almost  closed.  Finally,  at  the  end 
of  the  struggle,  the  conquerer  will  throw  up  his  auricles,,  in  token  of 
victory,  the  moment  he  obtains  the  advantage. 

It  is  a  well-known  fact  that  the  horse,  when  viciously  inclined, 
throws  his  ears  far  back,  an  act  analogous  to  that  of  a  desperately 
angered  person  who  shuts  his  eyes  to  the  consequences  of  his  own  in- 
considerate passion,  and  may  be  said  to  blindly  rush  on  to  his  own 
destruction;  so  might  one  fancy  that  the  horse,  by  means  of  this 
position  of. the  ears,  excludes  sound  to  some  extent,  and  thus  dulls 
one  of  the  senses  through  which  his  submission  might  be  brought 
about. 

Gallinacea,  and  probably  most  birds,  have  a  feathery  cluster  as  an 
outward  sound  collector,  the  auricle  existing  as  a  mere  protective 
cartilaginous  operculum  at  the  entrance  of  the  external  auditory 
canal.  The  external  auditory  canal  in  the  domestic  hen  being  large, 
the  parts  may  be  readily  studied  by  dissection.  The  writer  has  always 
found  the  membrana  tympani  to  be  also  comparatively  large — half 
the  size  of  that  in  man.  The  arrangement  of  the  membrane  lining 
the  canal  is  particularly  interesting;  this  is  not  attached  to  the  poste- 
rior and  superior  walls,  but  glides  freely  over  them,  being  directly 
continuous  with  the  membrana  tympani.  Some  muscular  fibres  seem 
to  blend  with  this  movable  fascia,  and  traction  applied  to  the  muscu- 
lar tissue  behind  the  ear  puts  it  on  the  stretch,  and  can  he  seen  to 
make  the  drum-head  tense.  The  semicircular  canals  are  known  to  be 
Tery  large,  but  the  writer  was  surprised  to  find  how  great  an  area  of 
the  temporal  bone  was  occupied  by  the  pneumatic  cellules,  which  are 
of  very  small  size. 

The  auricle  in  man  has  a  more  inflexible  framework,  and  is  much 
less  mobile  than  that  of  the  quadrupeds  described  above.  It  is  flat- 
tened out  rather  than  puckered  up,  but  the  tragus  projects  well  over 
the  lumen  of  the  canal,  affording  it  protection.  The  flexible  auricle 
of  the  dog,  when  unfolded,  presents  with  the  cartilaginous  canal  a 
cone-shaped  tube.  In  man,  the  outer  cartilaginous  parts  fall  away 
from  the  osseous  canal  into  which  they  are  telescoped  in  a  downward 
direction,  the  traction  of  their  weight  contributing  to  the  mainte- 
nance of  tension  in  the  transmitting  mechanism. 


MOVEMENTS    OF   THE   AUKICLE.  2^ 

THE  FUNCTIONAL   MOVEMENTS   OF  THE  AURICLE. 

The  cartilage  of  the  outer  ear  is  capable  of  very  much  more  motion 
than  many  suppose.  The  concha,  in  the  first  place,  is  bent  over  upon,, 
and  lies  in  close  contact  with  the  cartilage  of  the  canal,  and  may  easily 
be  lifted  away  from  it;  in  the  second  place^  the  cartilaginous  canal 
lies  loosely  in  its  place,  and  the  fissures  of  Santoriui  increase  the 
range  of  its  motion. 

It  has  been  stated  that  the  principal  point  of  connection  between 
the  auricle  and  the  temporal  bone  is  at  the  greatest  convexity  of  the- 
concha.  This  point  indeed  would  seem  to  be  the  axis  about  ivhich  the- 
auricle  may  be  revolved  rather  than  the  cartilaginous  canal. 

Now  it  will  be  seen  that  the  ligaments  which  support,  and  the 
muscles  which  act  upon  the  auricle  anteriorly,  are  attached  somewhat 
above  this  axis  to  the  tragus  and  spine  of  the  helix,  whilst  the  liga- 
ments which  support  and  muscles  which  retract  the  auricle  are  in- 
serted posteriorly  on  a  loioer  level  than  the  axis.  When  the  auricle  is 
drawn  forwards  by  the  anterior  muscles  it  rotates  on  the  axis;  when 
retracted  by  the  posterior  muscles,  a  similar  movement  takes  place.. 
The  superior  muscle  alone,  seldom,  if  ever,  acts  independently  so  as 
to  elevate  the  auricle,  although  it  does  so  in  connection  with  the  an- 
terior muscles.  The  tragus  partakes  of  but  little  of  the  auricle's 
motions.  AVhen  the  auricle  is  lifted  upwards  by  the  surgeon,  so  as. 
to  bring  the  cartilaginous  canal  on  a  line  with  the  osseous  portion,  in 
making  an  examination  of  the  deeper  parts,  it  first  glides  over  the 
cartilage  of  the  canal  to  a  considerable  extent  before  traction  is  trans- 
mitted to  the  canal  itself.  Further  traction  then  elevates  the  canal, 
its  transverse  fissures  increasing  the  length  of  the  anterior  wall,  while 
the  posterior  membranous  wall,  in  consequence  of  its  loose  attach- 
ment, is  bent  in  such  a  manner  as  to  become  shortened.  That  por- 
tion of  the  concha  lying  between  the  line  of  the  tragus  and  antitra- 
gus  glides  freely  up  and  down  in  the  space  between  the  ramus  of  the 
jaw  and  the  mastoid  process  when  traction  is  made  above  or  below — 
a  movement  very  much  facilitated  by  the  first  tubal  fissure.  The 
lower  edge  of  the  cartilage  of  the  concha  may  be  felt  Just  above  the 
lobule,  and  if  the  finger  be  placed  in  this  cavity,  and  pressure  down- 
ward be  made,  the  incisura  auris  may  be  felt  to  present  a  triangular 
groove  looking  upward. 

Persons  ivith  defective  hearing,  due  to  relaxation  of  the  integument 
covering  the  external  auditory  canal  and  drum-head,  frequently  prac- 
tise this  so  as  to  bring  the  integumentary  lining  into  a  state  of  ten- 
sion, and  thus  increase  the  hearing  power.     On  the  other  hand,  the^ 


30  VOLTTNTARY    MOVEMENES   OF   THE   AUEICLE. 

acuteness  of  hearing  may  he  decidedly  lessened  by  pressing  these  parts 
upwards  and  imvards. 

THE  VOLUNTARY  MOVEMENTS  OF  THE  AURICLE 

IN  MAN. 

Aside  from  affording  a  trumpet-like  channel  for  the  entrance  of 
sound  to  the  drum,  the  auricle  also  maintains  its  tension,  a  function 
due  to  its  elasticity.  Physiologists  have  long  accepted  the  theory  that 
the  proper  tension  of  the  drum-head  depends  on  intrinsic  tractile 
force  which  the  tensor  tympani  exerts — a  conclusion  reached  through 
deductions  drawn  from  accepted  principles.  The  observations  of 
many  years  in  the  field  of  practical  otology  have  led  the  author  to 
question  this  belief,  since  many  pathological  conditions  of  the  ear 
give  rise  to  phenomena  going  to  show  that  the  tractile  energy  on 
which  tension  of  the  drum-head  depends,  lies  rather  in  the  resilient 
cartilage  of  the  auricle.  The  induction  has  been  further  fortified  by 
(«)  studies  of  the  functions  of  the  hearing  organ  in  lower  animals,  (J) 
anatomical  studies  of  the  ear,  (c)  observations  of  ear  movements  in 
man,  especially  when  displayed  in  an  unusual  degree,  and  {d)  from 
the  phenomena  attending  morbid  conditions  of  the  auditory  apparatus. 
The  three  former  are  alluded  to  elsewhere  ;  the  fourth  remains  to  be 
considered. 

It  has  been  already  stated  that,  if  close  observation  is  made,  most 
persons  when  listening  exhibit  in  some  degree  the  unconscious  eleva- 
tion of  their  auricles.  The  muscles  by  whose  action  this  function  is 
performed  are,  as  is  known,  comparatively  feeble,  yet  they  are  suffi- 
cient for  the  requirements  of  the  auditory  apparatus  in  man.  The 
ability  to  voluntarily  move  the  auricle  possessed  by  some  is  a  strong 
argument  in  favor  of  evolution.  The  writer  has  observed  that,  per- 
haps, more  than  one-half  of  all  the  patients  examined  perceptively 
move  the  auricle  upward  and  forward  or  upward  and  backward,  on 
the  mere  contact  of  the  instruments  nsed  in  examination  or  treatment 
of  the  ear  ;  sometimes  this  action  actually  impedes  their  use,  the  pa- 
tient seeming  to  unconsciously  remove  the  organ  out  of  the  way.  In 
a  much  more  perfect  manner,  extraneous  objects  are  excluded  from 
the  ears  of  some  animals  whose  rudimentary  auricles  seem  specially 
provided  with  this  function.  Numerous  observations  have  shown 
that  the  faculty  of  using  these  muscles  varies  in  different  individuals; 
some  could  contract  either  the  frontalis,  orbicularis  palpebrarum,  or 
occipitalis,  while  others  could  not  make  the  former  act  without 
bringing  into  action  the  two  others.     The  orbicularis  alone  was  some- 


VOLUNTARY   MOVEMENTS    OF    THE    AURICLE.  31 

times  found  to  have  the  power  to  move  the  fascia  temporalis  and,  in 
consequence,  the  auricle  and  even  deeper  parts  of  the  organ. 

Arrectus  Auris :  A  friend  of  the  author's,  in  conversing,  always 
elevates  his  eyebrows  quite  unconsciously  while  listening,  by  con- 
tracting the  frontalis  muscle.  In  order  to  ascertain  if  the  acuteness 
of  hearing  was  thus  increased,  the  writer  placed  a  vibrating  tuning 
fork  just  out  of  the  perceptive  range  of  this  gentleman.  On  elevat- 
ing the  eyebrows  smartly,  the  vibrations  could  then  be  heard,  and 
when  the  former  were  again  relaxed  he  ceased  to  hear  them  ;  alter- 
nate contractions  and  relaxations  of  the  muscle,  rapidly  made,  caused 
the  sound  to  reach  his  ears  interruptedly,  some  object  seeming  to  be 
now  and  then  interposed,  as  he  expressed  it.  Similar  results  were 
obtained  with  a  watch  while  ticking.  An  observant  otologist  in- 
forms the  writer  that  he  has  known  a  person  who  always  elevated  his 
eyebrows  so  greatly  as  to  appear  supercilious  and  overbearing,  or  as  if 
he  seemed  to  doubt  what  was  being  said. 

In  consequence  of  old  age,  and  sometimes  in  younger  persons, 
from  certain  causes,  relaxation  of  the  skin  of  the  outer  parts  of  the 
ear  is  liable  to  occur,  giving  rise  to  loss  of  tension  in  the  drum-head  ; 
impairment  of  hearing  and  autophonia  are  then  liable  to  occur,  and 
patients  very  often  acquire  the  habit  of  placing  the  open  hand  behind 
the  auricle  io  draw  it  forward  tvhile  listening.  In  thus  increasing 
the  sound-collecting  capacity  of  the  organ  and  putting  the  parts  upon 
the  stretch,  hearing  is  considerably  aided.  Others  attain  the  desired 
result  of  making  the  drum-head  more  tense  by  placing  the  forefinger 
in  the  concha  and  making  traction,  and  even  shaking  the  auricle 
vigorously  while  drawing  it  outwardly.  While  these  manipulations 
affect  the  transmitting  mechanism  but  little  when  in  a  normal  state, 
yet  their  effects  are  notable  where  its  equilibrium  has  been  disturbed 
through  loss  of  tone  in  the  dermic  layer  of  the  drum-head  and  exter- 
nal auditory  canal.  Where,  furthermore,  autophonia  is  due  to  par- 
tial luxation  of  the  malleo-incudal,  incudo-stapedial,  or  stapedial- 
fenestral  articulations,  this  outward  traction  is  found  to  temporarily 
restore  tension  and  remove  the  disability.  It  is  probable  that  the 
temporary  improvement  of  hearing  by  inflation  of  the  drum  after 
Politzer's  method  is  accomplished  in  this  manner. 

Some  years  ago,  while  examining  a  patient,  the  temporalis  muscle 
was  observed  to  involuntarily  contract  on  touching  the  meatus  with  a 
speculum,  and  the  skin  infroyit  of  the  tragus,  luhicli  was  wrinkled 
before,  became  smooth  and  eveyi  tense.  The  patient,  who  could  contract 
these  parts  at  will,  informed  the  author  that  accompanying  the  ac- 
tion he  always  experienced  a  "  crack  "  in  the  ear.     From  the  notes  of 


82  VOLUNTARY    M0VEME2JTS    OF   THE   AUKICLE. 

many  subsequent  observations  on  this  subject,  the  following,  which 
offer  points  of  unusual  interest,  have  been  selected. 

Case  1. — Joseph  C ,  aged  14,  came  to  the  New  York  Ear  Dis- 
pensary, in  November,  1878,  on  account  of  defective  hearing  arising 
from  chronic  purulent  inflammation  of  the  middle  ear.  During  his 
examination,  it  was  observed  that  he  readily  pricked  up  his  ears  while 
listening,  the  auricle  presenting  well  forward.  The  act  seemed  to  be 
performed  as  if  to  aid  the  defective  sense  of  hearing,  and  he  was  ap- 
parently unconscious  of  the  movements  made.  When  requested  to 
move  his  ears,  however,  they  were  moved  forward  and  backward  with 
great  ease.  The  power  of  moving  the  ears  was  doubtlessly  increased 
by  the  constant  efforts  made  in  listening. 

Case  2. — This  case  was  that  of  a  friend  of  the  writer,  a  physician 
about  38  years  of  age,  of  slender  build,  and  having  free  muscular 
action  throughout.  At  school  he  was  noted  for  the  facility  of  ear 
movements.  By  the  conjoint  action  of  the  occipital  and  frontalis  mus- 
cles, he  could  elevate  and  displace  his  hat,  but  not  quite  throw  it  off 
the  head.  On  bringing  the  aural  muscles  into  play  for  the  writer's 
inspection,  it  was  found  that  long  disuse  had  in  a  manner  deprived 
him  of  the  power  once  possessed  in  moving  them,  and  the  efforts  made 
soon  tired  him.  After  resting  a  few  moments,  however,  he  was  able 
to  proceed  again;  when  the  occipital  muscle  was  now  contracted,  the 
fascia  containing  the  retrahens  auris  became  tense,  and,  by  the 
aid  of  the  auxiliary  force  on  either  side,  the  auricles  were  retracted 
and  bent  over  upon  themselves,  the  folding  commencing  at  the  anti- 
helix,  specially  along  the  posterior  superior  border.  Altogether  the 
auricle  was  drawn  upward  as  well  as  backward;  the  auriculo-cranial 
fibres  of  the  fascia  thus  put  on  the  stretch  were  felt  during  the  action 
to  be  very  tense.  No  ability  to  draw  the  auricle  forward  was  de- 
tected. 

Case  3. — Miss  Sarah ,  aged  22,  slender  and,  like  all  cases  of 

this  kind,  possessing  much  suppleness  of  movement.  Three  years  ago 
she  began  to  notice  the  ease  with  which  the  muscles  of  the  head  could 
be  brought  into  action;  at  first  she  observed  that  she  could  move  ''  the 
top  of  the  head,"  and  shortly  afterwards  the  ears.  On  request,  she 
brought  the  occipital  and  frontal  muscles  into  violent  action  with 
great  ease,  then  elevated  the  brows,  and  contracted  the  orbicularis  in- 
dependently. The  demonstration  of  ear  movements  on  both  sides  was 
very  remarkable.  By  the  action  of  the  occipitalis  and  posterior  au- 
ricular, the  auricles  could  be  drawn  backwards  and  slightly  upwards 
with  great  promptness  and  energy.  A  finger  placed  just  behind  the 
auricle,  on  a  plane  with  the  external  auditory  canal,  detected  vigor- 
ous contractions  of  the  retrahens  and  fascia  in  which  the  latter  lies; 
even  the  integument  in  front  of  the  concha  was  drawn  towards  that 
part,  and  the  skin  below  the  auricle  and  down  over  the  side  of  the  face 
and  neck  for  some  distance  was  visibly  affected.  There  seemed  to  be 
quite  a  decided  independent  action  of  the  retrahens  muscles,  the  ears 
to  all  appearances  being  moved  at  will  by  these  muscles;  but  when 
aided  by  the  occipital  and  frontal  muscles,  the  ears  could  be  moved 


VOLUNTARY    MOVEMKNT.^    OP'    THE    AUKICLE.  33 

much  more  decidedly.  The  latter  experiment  being  kept  up  some 
minutes,  she  complained  of  being  tired;  in  fact,  several  vigorous  con- 
tractions always  make  her  dizzy — a  phenomenon  seemi7igly  due  to  the  con- 
cussions imparted  to  the  fluid  in  the  labyrinth.  She  said  that  during 
the  ear  movements  she  could  "  feel  something  move  inside  her  face." 
This  suggested  that  contraction  of  the  tensores  tympani,  together 
tuith  the  tensores  pnlati,  had  taken  place,  and,  on  making  the  attempt, 
it  was  found  that  this  could  be  voluntarily  done.  When  the  tensors 
of  the  palate  were  thus  in  a  state  of  contraction,  exterior  noises 
seemed  distant,  and  a  peculiar  ''vacuum"  in  the  ears  was  experienced. 
The  following  acoustic  observations  were  now  made: 

It  ivas  found  that  a  ticking  watch  could  he  heard  nine  feet,  hut  if 
moved  several  inches  further  aivay,  she  could  again  hear  it  on  drawing 
up  the  auricles,  as  before.  If  the  ivatch  was  now  held  in  front  of  the 
face,  it  was  tv ell  heard  at  the  distance  of  five  feet,  hut  if  the  tensors 
of  the  palate  and  tensor  tympani  loere  now  contracted,  it  could  no 
longer  be  heard.  When  she  ceased  to  contract  these  muscles,  a  peculiar 
sound  was  experienced  in  the  ears  and  hearing  returned.  It  was 
observed  that  the  auricle,  while  under  muscular  dominance,  after 
being  drawn  a  certain  distance  either  backwards  or  forwards,  was 
slightly  rotated  on  the  axis  of  its  ligamentous  attachment  to  the 
skull. 

Case  4. — Eugene  F  ,  aged  22  years.  Frenchman,  of   slender 

physique.  Through  the  action  of  the  occipital  and  frontal  muscles, 
this  person  can  move  the  scalp  with  extraordinary  freedom;  when 
the  muscles  act  independently  of  each  other,  the  ears  are  drawn 
either  backwards  or  forwards.  When  drawn  well  back,  if  traction 
be  maintained,  the  helix  is  bent  over  upon  the  auricle.  The  tem- 
poral and  post-aural  fascia  can  be  seen  and  felt  to  move  during 
the  action  described.  This  exercise  gives  rise  to  a  tingling  sensa- 
tion at  the  sides  of  the  nose  and  about  the  auricle;  subsequently, 
these  parts  have  an  "  exhausted  feeling ''  like  any  other 
region  under  severe  muscular  usage.  He  can  hear  the  ticking  of  a 
watch  much  farther  when  the  auricle  is  drawn  in  an  upward  direc- 
tion. He  is  musical  and  when  listening  to  orchestral  music  often 
finds  himself  wagging  his  ears  to  the  time  of  the  air  being  played. 
The  auricle,  during  some  of  the  exercises,  was  seen  to  rotate  con- 
siderably upon  its  axis,  and  after  a  time  became  deeply  flushed; 
when  erected  it  was  held  rigidly  against  the  temporal  bone.  AVhen 
the  auricle  was  taken  by  the  helix  and  drawn  forward,  the  tendons 
of  the  posterior  auricular  stood  out  plainly  on  voluntary  contrac- 
tion being  made;  it  returned  to  its  place  when  the  muscles  were 
voluntarily  relaxed.  These  muscles  become  more  or  less  inert  after 
exercise,  but  after  a  few  moments'  rest  their  use  would  return. 

Case  5. — This  patient  is  a  German  teacher,  aged  29  years.  By 
voluntarily  contracting  the  orbicularis  palpebrarum,  the  temporal 
fascia  is  made  sufficiently  tense  to  draw  the  auricle  forward  and 
upward;  the  fibres  attached  to  the  anterior  border  of  the  helix  during 
this  action  become  so  tense  that  they  feel  like  the  tendon  of  some 
strong  muscle.  The  tragus  remains  fixed  during  the  ear-movements, 
3 


34  VOLUNTARY   MOVEMENTS   OF   THE   AURICLE. 

while  the  posterior  wall  of  the  cartilaginous  portion  of  the  external 
auditory  canal  is  advanced  considerably,  increasing  the  vertical  diam- 
eter of  the  lumen,  at  the  expense  of  its  longitudinal  diameter.  The 
occipital  and  frontal  muscles  have  a  free  action  also,  but  the  action  of 
the  orbicularis  was  quite  independent  of  these. 

Case  6. — Mabel ,  aged  13  years,  of  slender  build.  Can  volun- 
tarily move  the  auricles  both  upward  and  backward,  the  superior 
border  of  helix  being  slightly  bent  upon  the  auricle.  When  the 
•speculum  is  gently  introduced  just  within  the  meatus,  the  skin  of  the 
canal  can  be  seen  to  move  outwardly  when  the  auricle  is  drawn 
backwards. 

Examples  like  the  above  might  be  multiplied  ad  infinitum,  since 
in  a  large  number  of  young  and  slightly  formed  persons  these  phe- 
nomena can  be  plainly  seen. 


CHAPTER    11. 

OBSERVATIONS   ON   THE    TRANSMITTING    MECHANISM 
OF  THE    DRUM    OF   THE  EAR. 

The  drum  is  not  a  sound-producing  instrument. in  the  ordinary 
sense,  and  when  the  drum-head  is  beaten  upon  by  the  gentle  pulses 
of  the  air  no  perceptible  aerial  sound  is  given  forth,  but  the  drum- 
skin  is  set  in  motion  by  the  undulatory  movements,  constituting 
sound,  and  its  propulsive  action,  through  the  malleus  and  incus  bones, 
sets  the  piston-like  stirrup  bone  in  motion,  thus  giving  rise  to  vibra- 
tions of  the  labyrinthine  fluid  and  motions  of  the  otoliths.  Similar 
action  may  take  place  in  the  cochlea  through  vibrations  also  set  up  in 
the  membrana  tympani  secundaria.  The  drum  of  the  ear  or  tympa- 
num, therefore,  receives  and  transmits  sound.  This  portion  of  the 
auditory  tract  constitutes  what  may  be  designated  the  aerial  region. 
Before  speaking  further  of  the  modus  operandi  of  hearing,  a  brief 
description  of  the  anatomy  and  physiology  of  the  parts  will  be  given 
in  order  to  make  the  subject  more  readily  understood. 

A.      THE    DRUM    OF   THE   EAR. 

The  boundaries  of  the  drum  (middle  ear)  are:  inwardly,  the  osseous 
tympano-labyrinthine  partition;  outwardly,  the  drum-head;  and  lat- 
erally, an  almost  continuous  narrow  wall.  The  drum  is  very  shallow, 
being  only  a  few  lines  in  depth.  Its  inner  and  outer  boundaries  are 
almost  fiat;  its  lateral  aspect  circular.  It  has  a  free  vent  into  the 
throat  by  means  of  the  Eustachian  tube,  and  communicates  with  an 
extensive  but  irregularly-formed  air  chamber,  the  mastoid  antrum, 
through  a  tolerably  large  bony  canal  and  the  cellules  of  the  mastoid 
and  neighboring  parts.  Because  of  its  moist  lining  and  other  charac- 
teristics, the  drum  is  not  ordinarily  resonant,  but  should  in  this 
connection  be  regarded  simply  as  a  transmitting  mechanism. 

For  an  anatomical  description  of  the  bony  parts  of  the  middle  ear, 
the  reader  should  consult  Chapter  XI. 


36 


TRANSMITTING   MECHANISM   OF   THE    DRUM. 


B.       THE   MEMBRANA    TYMPANI. 


The  drum-head  is  a  thin,  elastic,  membranous  partition  stretched 
over  the  bottom  of  the  external  auditory  canal,  pearly  white  in  color, 
and  polished.  In  its  tissue  the  handle  of  the  hammer  is  so  fixed  that 
it  partakes  of  its  movements. 


Fig.    9. — Outer  Surface  of  Drum-head 
(Gruber). 
A,  Manubrium  of  malleus;  B,  short  pro- 
cess; C,  tip  of  the  manubrium,  the  umbo; 
D,  posterior  fold. 


Fig.  10. — Inner  Surface  of  Druh-head 
(Gruber). 
A.  Manubrium  of  malleus;  B,  umbo,  or 
tip  of  the  manubrium;  C,  head  of  the 
malleus;  D,  body  of  incus;  E,  short  pro- 
cess of  incus;  F,  processus  lenticularis  of 
incus;  G,  H,  chorda  tjanpani;  I,  insertion 
of  tensor  tympani  muscle. 


It  is  divided  horizontally  into  two  unequal  portions,  to  which 
Shrapnell  gave  the  names  of  membrana  flaccida  and  membranatensa.* 
The  smaller,  the  memhrana  flaccida,  Shrapnell's  membrane,  or,  as  it 
might  be  properly  called  with  respect  to  its  functions,  the  tensor  of 
the  memhrana  vibrans  is  situated  above,  whilst  the  larger,  the  mem- 
brana vibrans  or  tensa  is  placed  below.  Each  portion  has  different 
functions. 

The  membrana  flaccida  is  continuous  with  the  integument  lining 
the  external  auditory  canal  which,  after  passing  over  the  vaulted  upper 
wall  of  the  canal,  curves  downward  at  a  very  obtuse  angle,  passing 
over  the  gap  which,  in  infancy,  is  left  between  the  horseshoe-like 
annulus  tympanicus,  as  it  rises  to  the  auditory  plate;  it  is  then 
reflected  off  the  edge  of  the  auditory  plate,  and  passes  downward 
somewhat  in  front  of  the  atticus  tympanicus. 

The  membrana  vibrans  or  tensa  is  stretched  below  in  front  of  the 
atrium,  and  is  framed  into  the  groove  at  the  end  of  the  external 
auditory  canal. 

The  external  face  of  the  membrana  tympani  is  concavo-convex  ; 
from  above  the  malleus  handle  may  be  seen  to  extend  down  along 

'  On  the  Form  and  Structure  of  the  Membrana  Tympani.  By  Henry  Jones 
Shrapnell.    The  London  Medical  Gazette,  April  28th,  1833,  p.  122. 


TKANSMITTING    MECHANISM    OF    THE    DRUM.  37 

its  median  diameter  ending  near  the   centre  in  a  depression,  the 
umbo. 

The  projection  of  the  short  process  of  the  mallens  handle  pushes 
outwards  the  membrane  at  the  junction  of  the  two  portions  of  the 
latter.  The  membrana  vibrans  is  attached  below  at  an  acute  angle  with 
the  floor  of  the  drum,  to  its  anterior  wall  at  an  acute  angle,  and  to 
its  posterior  wall  at  an  obtuse  angle.  It  forms  an  angle  of  55°  with 
the  axis  of  the  canal,  and  one  of  15'^  with  the  longitudinal  axis  of 
the  body. 

C.      THE   MUSCLES    OF   THE    DRUM. 

The  muscles  of  this  part  of  the  auditory  apparatus  are  those  of  the 
malleus  and  stapes. 

1.  M.  tensor  tynqmni,  or,  as  it  has  been  called,  M.  mallei  internus, 
arises  from  the  anterior  mouth  of  the  muscular  and  upper  wall  of  the 
cartilaginous  portion  of  the  Eustachian  tube,  ''  from  the  pyramidal 
petrous  portion  of  the  temporal  bone,  which  here  forms  the  lateral 
and  anterior  wall  of  the  carotid  canal  .  .  .  also  from  the  neighboring 
edge  of  the  temporal  wing  of  the  sphenoid,  where  it  unites  with  the 
origin  of  the  spheno-staphylinus  muscle  (see  p.  48)  by  tendinous 
and  ofttimes  muscular  fibres"  (Henle).  It  traverses  upon  the  Eus- 
tachian tube,  becoming  surrounded  by  a  fibrous  sheath,  from  which 
start  some  of  its  fibres.  "  It  passes  over  the  septum  tubae  into  the 
canal  of  the  tensor  tympani  which  it  traverses  from  one  end  to  the 
other,  fortified  by  short  oblique  fibres  arising  from  the  superior 
wall  of  the  canal.  Just  before  its  exit  into  the  canal  it  assumes  the 
form  of  a  cylindrical  tendon,  which  winds  around  the  cochleaform 
process  and  then  passes  through  the  tympanum  at  right  angles  to 
the  body  of  the  muscle"  (Henle),  and  is  attached  on  the  upper  end 
of  the  median  edge  of  the  handle  opposite  the  short  process.  The 
tendon,  according  to  Sappey'  and  Helmholtz,'  is  contained  in  a  sheath 
(tensor  ligament  of  Toynbee)  which  is  lined  with  a  synovial  mem- 
brane, but  Magnus  claims  that  it  is  only  covered  by  the  mucous 
membrane  of  the  drum,  strengthened  by  firm  submucous  tissue. 
The  otic  ganglion  furnishes  the  motor  nerve  of  this  muscle.  Po- 
litzer^  and  Ludwig  have  proved  by  experiments,  however,  that  the 
motor  elements  of  this  nervus  ad  te?isorem  tympani  belong  to  the 
motor  portion  of  the  trigeminus. 

^  Anatomy,  p.  541. 

*  Die  Mechanik  der  Qehoerknoechelchen  und  des  Trommelfells.  Pfliiger's 
Archiv  fur  Physiologie,  I,  Jahrgang. 

3  Diseases  of  the  Ear.    Trans,  by  J.  P.  Cassells,  Pliila.,  1883,  p.  44. 


38  TRANSMITTING    MECHANISM   OF   THE   DRUM. 

Its  action,  according  to  most  authorities,  is  to  pull  the  hammer 
inward  and  to  turn  it  about  its  longitudinal  axis,  which  action 
Kessel  believes  stretches  the  anterior  segment  more  than  the  pos- 
terior, thus  admitting  of  a  simultaneous  perception  of  high  and  low 
tones.  But  opinions  differ  in  regard  to  the  functions  of  this  muscle. 
Magnus,'  for  instance,  thinks  the  muscle  is  too  firmly  attached  in 
the  canal,  and  its  tendon  in  the  mouth  of  the  canal,  to  exert  any  in- 
fluence on  the  membrana  tympani.  He  regards  its  function  (and 
also  that  of  the  stapedius  muscle)  as  confined  to  aiding  the  elastic 
resisting  power  of  the  tissue  which  surrounds  the  tendons  at  their 
point  of  exit.  Henle'  says  the  action  of  these  muscles  is  necessarily 
limited,  since  the  bony  walls  in  which  they  lie  prevent  the  swelling 
necessary  to  much  contraction.  The  muscles  do  not  maintain  the 
position  of  the  drum-head  as  much  as  their  sheaths. 

2.  The  stapedius  muscle  starts  from  the  depths  of  its  bony  canal, 
at  the  base  of  the  eminentia  stapedii.  The  belly  of  the  muscle  fills 
the  canal  and,  becoming  thinner  and  pointed,  it  passes  out  of  its 
opening  on  the  pyramid  in  the  form  of  a  brilliant,  bristle-like  tendon 
of  one  line  in  length,  which,  according  to  Huschke," ''rolls  on  the 
rounded  edge  like  a  pulley.''  The  tendon  forms  with  ,the  axis 
of  the  pyramid-shaped  muscle  an  obtuse  angle,  opening  down- 
wards, and  passes  over  to  the  head  of  the  stapes  to  be  inserted  just 
under  the  edge  of  the  articular  surface  of  the  latter.  ^  A  few  fibres, 
according  to  Riidinger,  go  to  the  capsule  on  the  lenticular  process  of 
the  incus. 

The  tendon,  as  the  writer  himself  has  seen  in  the  infant  at  birth, 
passes  in  an  almost  direct  line  forward  from  the  pyramid  to  the 
stapes. 

A  branch  of  the  facial,  passing  from  the  facial  canal  directly  in  to 
the  base  of  the  stapedial  eminence,  furnishes  the  motor  nerve  for  this 
muscle. 

Regarding  the  functions  of  the  stapedius  there  is  considerable 
controversy.  Some  authorities  have  maintained  that  the  action 
of  this  muscle  was  to  draw  the  stapes  into  the  oval  window, 
others  out,  others  obliquely,  others  to  turn  it  on  its  own  axis, 
at  one  time  therefore  an  aid,  at  another  an  antagonist  to  the  tensor 
tympani  (Henle).  In  speaking  of  this  muscle,  Huschke  advances 
the  theory  that  the  stapedius,  in  drawing  backwards  the  stapes,  ought 
also  to  make  traction  upon  the  descending  branch  of  the  incus,  thus 

'  Henle,  Anatomie,  vol.  2,  p.  781. 

'■'  Splanchnologie, 

*  Henle,  Anatomie,  vol.  2,  p.  780. 


TRANSMITTING  MECHANISM    OF   THE    DRUM.  39 

causing  the  body  of  the  latter  to  act  on  the  hammer  in  such  a  way  as 
to  relax  the  drum-head,  becoming  in  this  manner  antagonistic  to  the 
M.  tensor  tympani. 

It  appears  to  the  writer  that  the  functions  of  the  muscles  connected 
with  the  transmitting  apparatus  have  been  both  overrated  and  under- 
estimated; thus  to  the  tensor  tympani  has,  perhaps,  been  assigned  too 
much  power  in  maintaining  the  tension  of  the  mechanism,  whilst  to 
the  exterior  muscles  too  little  has  been  ascribed. 

It  would  seem  that  tension  was  entirely  due  to  the  resiliency  of  the 
cartilaginous  framework  of  the  external  auditory  canal  and  auricle, 
aided  by  the  exterior  muscles  of  the  ear,  and  to  the  intra-tympanal 
support  mentioned  elsewhere. 

The  intra-tympanic  muscles  (tensor  tympani  and  stapedius)  would 
appear  to  have  for  their  function  the  restoration  of  tension  whenever 
intra-tympanic  air-renewal  or  other  cause  forces  the  drum-head  out- 
wardly. 

The  first  named  muscle  is  actually  a  continuation  of  the  tensor  palati 
(see  p.  48)  and  when  acting  in  sympathy  with  it  aids  in  restoring 
tension  by  traction  made  upon  the  malleus  simultaneously  with  the 
entrance  of  air  into  the  drum.  Both  of  these  muscles,  as  is  known, 
receive  a  nervous  filament  from  the  otic  ganglion.  From  his  own 
dissections,  and  a  study  of  the  physiology  of  the  subject,  the  author 
is  convinced  that  the  stapedius,  acting  at  the  same  time,  aids  in  this 
restoration.  This  function  of  the  stapedius  may  be  better  compre- 
hended from  a  study  of  the  incudo-stapedial  articulation. 

The  long  process  of  the  incus  springs  out  of  the  body  of  the  bone 
when  in  situ  in  a  downward  and  slightly  anterior  direction,  but  about 
midway  it  begins  to  curve  back  again  posteriorly  and  inwardly.  The 
inferior  extremit}^  is  bent  upon  the  shank  at  about  a  right  angle,  the 
tip  upon  which  the  lenticular  process  is  situated  fitting  into  the  cup- 
shaped  cavity  of  the  head  of  the  stapes.  This  articular  surface 
looks  inwardly;  its  convexity  forms  with  the  concave  surface  of  the 
head  of  the  stapes  a  ball-and-socket  joint,  separated  by  a  cartilage 
somewhat  resembling  the  tempore  maxillary  articulation. 

Now,  when  the  membrana  tympani  has,  from  any  cause,  been  made 
to  move  outwardly,  the  lenticular  process  glides  anteriorly  over  the 
meniscus,  since  the  pressure  through  the  malleo-incudal  articulation 
is  removed,  the  incus  following  the  malleus.  This  movement  relaxes 
the  incudo-stapedial  articulation.  If  traction  from  behind  now  be 
made  upon  the  head  of  the  stapes  by  the  action  of  the  stapedius 
muscle,  the  lenticular  process  will  be  made  to  glide  back  again  upon 
the  cartilage  as  a  fulcrum,  the  consequent  impingement  fixing  the 


40  TRANSMITTING   MECHANISM   OF   THE   DRDM. 

stapes  in  the  oval  window.  It  is  probable  that  tension  is  also  in- 
creased by  the  action  transmitted  to  the  shank,  causing  it  to  turn 
slightly  upon  the  axis  of  its  long  diameter,  and  thus  aiding  in  the 
Sxation  of  the  malleo-incudal  articulation.  Since  tension  of  the 
transmitting  mechanism  is  partially  lost  with  every  sound  vibration 
received  and  with  each  act  of  intra-tympanal  air- renewal,  and  is  dis- 
turbed also  by  certain  physiological  functions,  such  as  respiration, 
swallowing,  and  the  like,  some  means  is  required  for  its  instantane- 
ous restoration  ;  the  contraction  (reflex  ?)  of  the  tensor  tympani  and 
stapedius  would  seem  to  perform  this  function  rather  than  maintain 
tension  hy  constant  muscular  exertion. 

It  affords  the  writer  great  satisfaction  to  find  that  observations  of  a 
similar  nature  have  been  recently  made  by  other  authors.  In  a  work 
by  Prof.  G.  Schwalbe,  that  author  makes  the  following  remarks  con- 
cerning the  action  of  the  tensor  tympani ;'  "  Eegarding  the  action 
of  the  tensor  tympani,  I  desire  to  call  especial  attention  to  the  con- 
nection frequently  found  between  it  and  the  tensor  veli,  and  to  the 
innervation  of  both  of  these  muscles  from  the  same  source.  It  is 
extremely  likely  that  the  contraction  of  the  tensor  veli  palatini  is 
accompanied  by  contraction  of  the  tensor  tympani.  Since  contrac- 
tion of  the  first  opens  the  tuba,  giving  rise  at  the  same  time  to  fluctu- 
ations of  intra-tympanic  pressure,  it  is  probable  that  the  importance 
of  the  tensor  tympani  for  the  membrana  tympani  lies  in  the  power  of 
the  former  of  regulating  the  tension  of  the  drum-head  to  the  differ- 
ences of  pressure  existing  between  the  air  in  the  external  auditory 
canal  and  that  within  the  drum.'' 

The  connective  tissue  and  mucous  membrane  composing  the  sheath 
of  the  tendons  of  these  muscles,  moreover,  give  support  to  the  mechan- 
ism, and  perhaps  afford  some  resistance  to  outward  traction  by  their 
rigidity.  The  delicacy  of  this  mechanism  is  almost  inconceivable 
when  contrasted  with  muscular  action  elsewhere,  and  very  slight 
causes  may  disturb  its  equilibrium.  Where  any  defectiveness  in  the 
transmitting  mechanism  exists,  even  reflex  contractions  of  the  muscles 
themselves  may  give  rise  to  anomalies  of  audition. 

It  should  be  kept  in  mind  that  the  exterior  or  skin  muscles  are 
opposed  to  these  interior  muscles,  inasmuch  as  they  aid  in  the  main- 
tenance of  outward  tension  by  their  action  on  the  cranial  aponeurosis 
and  auricular  cartilage.  They  not  only  are  capable  of  moving  the 
auricle  in  certain  directions,  and  of  dilating  the  meatus,  but  they  also, 
through  traction  upon  the  exterior  parts,  affect  the  tension  of  the 
drum-head. 

^  Lehrbuch  der  Anatomie  des  Ohres.    Erlangen,  1887,  p.  508. 


TRANSMITTING    MECHANISM    OF    THE    DRUM.  41 

It  would  seem  probable  that  these  groups  of  intrinsic  and  extrinsic 
muscles  act  automatically,  probably  through  reflex  influences,  and 
have  an  antagonistic  relationship  towards  each  other. 

3.  M.  Laxator  tympani  major  {'^ommewmg) ,  or  i\\e  external  muscle 
of  the  hammer,^  fibrous  in  appearance,  ta'kes  its  origin  from  the  spina 
angularis  of  the  great  wing  of  the  sphenoid,  also  by  fibres  from  the 
cartilaginous  portion  of  the  Eustachian  tube,  and  from  the  bucco-pha- 
ryngeal  aponeurosis,  from  which  triple  insertion  it  passes  obliquely 
outwards  and  backwards  parallel  to  the  fissure  of  Glaser  under  which 
it  lies  ;  it  then  by  a  small  tendon  .passes  into  a  hole  of  this  fissure  and, 
blending  with  the  anterior  aponeurosis  of  the  hammer^  is  inserted  on 
the  neck  of  the  bone  above  the  root  of  the  long  or  anterior  process 
(Huschke).^  According  to  Hyrtl  its  tendon  is  inserted  on  the  long 
process  of  the  hammer,  but  Henle  describes  it  as  beiug  inserted  in  a 
fossa  on  the  lateral  surface  of  the  head  of  the  hammer.  This  muscle 
has  been  described  by  Folius,  and  has  since  been  shown  in  anatomi- 
cal manuals  and  engravings.  Its  muscular  nature  has  been  ques- 
tioned by  numerous  authorities,  such  as  Breschet,  Arnold,  Hagenbach, 
J.  Miiller,  Lincke,  Huschke,  and  Verga,  all  of  whom  regard  it  as  a  liga- 
ment. Henle^  says  his  own  careful  examinations  did  not  reveal  the 
presence  of  an}'  striated  muscular  fibres.  Hyrtl,*  on  the  contrary, 
believes  in  its  muscular  nature,  as  do  also  C.  Krause  and  Moskwin. 
Treviranus  (author  of  "  Erscheinungen^'),  says  Huschke,  found  the 
muscle  very  large  in  the  fox,  and  placed  "  in  a  bony  closed  cell  be- 
tween the  promontory  and  the  head  of  the  hammer  ;  it  was  composed 
of  muscular  fibres  starting  in  rays  from  a  tendon  lodged  in  the  middle 
of  the  mass."  "  The  tendon  was  inserted  at  the  end  of  the  long  (an- 
terior) process  of  the  hammer,  by  means  of  which  it  acted  verj;ically 
on  the  hammer  to  stretch  the  drum-head.  In  the  mole  it  was  found 
to  be  larger  still  in  proportion,  but  long  and  conical.  According  to 
Eudolph,  it  acts  with  the  interior  muscle  as  a  tensor  to  the  membrana 
tympani."  Huschke,  as  already  stated,  regards  the  existence  of  this 
muscle  in  man  as  very  doubtful.  The  writer  has  himself  observed 
the  apparent  existence  of  this  muscular  structure  just  mentioned,  in 
the  cat,  but  has  never  studied  its  relations  or  functions.  The  use  of 
this  muscle,  according  to  Sappey,  would  be  to  draw  the  hammer 
forward  and  without,  consequently  relaxing  the  drum-head. 

1  Called  also  :  Lig.  mallei  anterius  Arnold  ;  Lig.  mallei  tympani  Moskwin; 
M.  mallei  ant.,  s.  Folii,  s.  obliquus  s.  processus  minimi  mallei  Valsalva,  s.  spi- 
Moso-mallearis  Schreger. 

^  Splanchnologie. 

^  Anatomie.    Vol.  2,  p.  777. 

••  Lehrbuch  der  Anatomie  des  Menschen.     14th  Ed.,  Wien,  1878,  p.  621. 


42  TRANSMITTING   MECHANISM    OF   THE   DRUM. 

4.  M.  Laxator  tymj)ani  minor  oi  Sommerrmg  or  ot  Casserius,  called 
also  the  superior  muscle  of  the  hammer,'^  is  still  more  problematical,  . 
says  Huschke,  than  the  preceding  muscle.  It  is  said  to  start  by  ten- 
dinous fibres  from  the  superior  and  posterior  edge  of  the  external 
auditory  canal  above  the  drum-head,  descend  within  and  forwards, 
and  becoming  contracted,  pass  between  the  lamina  of  the  membrane 
to  be  inserted  into  the  external  edge  of  the  malleus  above  its  attach- 
ment to  the  tympanum,  and  also  to  the  short  process.  Huschke  could 
not  discover  striated  muscular  fibres,  nor  do  such  authorities  as  Val- 
salva, Vieussens,  Morgagni,  Casselbohm,  Meckel,  Haller,  Treviranus, 
Hagenbach,  J.  Miiller,  Bonnafont,  Krause,  and  Hyrtl"  recognize  its 
muscular  nature.  Supposing,  says  Huschke,  that  this  fibrous  band 
had  any  action,  it  would  be  to  pull  the  handle  towards  the  drum-head, 
consequently  relaxing  the  latter. 

Having  now  considered  some  of  the  more  important  points  in  the 
anatomy  of  the  drum  itself,  it  will  be  well  to  take  up  those  of  the 
throat,  with  which  the  former  is  intimately  connected. 

^  Called  also  :  M.  mallei  extemus  minor, s.  superior malleiWildherg,  s.  pro- 
cessus minoris  Valsalva,  s.  tympano-mallearis  Schreger;  ligamentum  mallei 
post.,  8.  manubrii  Lincke. 

*  Anatomie,  p.  623. 


CHAPTEE   III. 

THE   EELATIONS  OF    THE    NASO-PHAEYNX  WITH   THE 

DKUM  OF  THE  EAR  AND  THE  AERATION  OF 

THE  TYMrANUM. 

The  ear  drums,  or,  more  compreherisivel}'  speaking,  the  two  mid- 
dle ear  tracts,  constitute  the  superior  termini  of  that  ascending' 
portion  of  the  upper  air  tract  which  has  for  its  commencement  in  the 
naso-pharynx- the  Eustachian  tubes.  The  Eustachian  tubes  are  the 
most  important  of  all  the  connecting  channels  of  the  region  of  the 
head,  affording  a  passage  for  the  necessary  air-supply  to  the  drums, 
without  which  their  development  is  defective,  and  the  maintenance 
of  the  equilibrium  of  the  transmitting  mechanism  impossible.  These 
tubes  also  afford  a  means  of  escape  for  the  secretions  from  the  drums 
to  the  throat. 

The  Eustachian  tube  begins  in  the  naso-pharynx'  with  an  oval, 
trumpet-like  mouth;  but  since  the  air  which  traverses  it  from  without 
Is,  for  the  most  part,  first  sucked  in  through  the  capacious  expansion 
of  the  bony  and  cartilaginous  framework  constituting  the  nose,  its 
actual  beginning  corresponds  in  capaciousness  to  its  analogous  out- 
ward expansion  on  the  side  of  the  head,  namely,  the  sound-collecting 
auricle.  ^ 

The  modus  operandi  of  aerial  movements  in  the  upper  air  tract  re- 
quires the  otologist's  special  attention  in  connection  with  intra- 
tympanal  air-renewal,  and  since  these  are  inseparably  connected  with 
the  functions  of  respiration  and  deglutition,  it  will  be  necessary  to 
present  somewhat  fully  the  entire  scheme  by  means  of  which  air 
reaches  the  tympanic  cavity  with  such  regularity. 

Fig.  11,  from  Gray,  shows  at  a  glance  the  arrangement  of  the 
muscles  of    the  palatal   region,  and  which  are   concerned  in  regu- 

The  comparative  anatomy  of  this  region  of  the  ear  suggests  an  original 
adaptation  for  hearing  in  an  aqueous  element,  but  that  the  accession  of  the 
tympanic  membrane  to  the  structure  necessitates  an  aerial  equilibi'ium  in 
which  it  may  oscillate  freely  when  agitated  by  sound  vibrations. 


44 


RELATIONS  OF    THE    NASO-PHARYNX. 


lating  the  circulation  of  air  in  this  region.  For  their  description  the 
reader  is  referred  to  works  on  anatomy ;  reference  to  their  special 
functions  in  this  connection  will  be  made  further  on.  The  pneumatic 
area  in  man  will  be  divided  for  convenience  of  study  here  into  two 
systems,  namely,  the  pulmonary  and  naso-pharyngeal,  or  lower  and 
upper.    These  regions  may  be  likened  to  an  elastic  rubber  air  bag  di- 


vided unequally,  as  shown  in  the  accompanying  diagrammatic  illus- 
tration (Fig.  12),  into  a  large  and  small  chamber,  but  communicating 
with  each  other  by  a  constricted  passage.  The  air  supply  of  both  of 
these  reservoirs  is  first  received  into  the  smaller  chamber,  mainly 
through  the  two  nasal  passages,  air  in  the  normal  state  in  man  enter- 
ing only  exceptionally  through  the  mouth,  which  is  adapted  more 
particularly  for  the  reception  of  food  and  drink. 


RELATIONS    OF   THE   NASO-PHARYNX. 


45 


As  is  well  known,  the  pulmonary  cavity  receives  its  air  supply  by 
means  of  the  suction-force  occasioned  by  descent  of  the  diaphragm 
and  elevation  of  the  thorax  ;  during  this  act  considerable  rarefaction 
of  air  in  the  pharynx  and  tympanum  takes  place — the  soft  palate 
descending  along  with  the  current  of  air,  which,  entering  the  nostrils 
and  then  passing  down  into  the  lungs,  constitutes  the  act  of  inspira- 
tion. That  air  is  thus  withdrawn  from  the  tympanum  through  rare- 
faction in  the  naso-pharynx  is  proven  by  the  phenomenon  which  may 


Fig.  18.— Diagram    of   the  Upper"^  and    Lower   Respiratory   Passages.     (Drawn  for  the 
Author  by  Dr.  Robert  Barclay.) 

H,  P,  Line  showing  the  level  of  the  hard  palate,  separating  the  upper  from  the  lower  air 
tract;  T,  tympanum,  communicating  with  the  pharynx  through  E.t,  the  Eustachian  tube. 

be  observed  in  certain  cases  where  the  membrana  tympani  is  relaxed, 
or  when  a  large  manometrio  cicatrix  in  the  drum  -head  exists ;  for 
under  such  conditions  the  membrane  is  seen  to  be  indrawn  with  each 
inspiratory  act. 

The  air  remaining  in  the  lesser  receptacle  (above  the  soft  palate)  at 
the  completion  of  the  respiratory  act  is  (on  expiration)  condensed 


46 


RELATIONS    OF   THE   NASO-PHARYNX. 


by  the  outgoing  current  from  the  lungs,  some  of  it  passing  along  up 
the  Eustachian  tube  to  the  tj'mpanic  cavity.  It  would  seem  that, 
though  the  expiratory  current  passes  out  of  the  nose  (or  mouth) 
with  considerable  momentum,  that  the  comparatively  slight  conden- 
sation of  air  which  takes  place  in  the  pharynx  is  sufficient  to  insure 
the  necessary  air  renewal  of  the  tympanum.  But  intra-tympanic  air- 
renewal  does  not  altogether  depend  upon  this  method  ;  it  also  takes 


1    Head  of  malleus. 

2,  Eteflected  tendon  of  tensor  tympani. 

'i,  Processus  cochleaformis. 

4,  Osseous  portion  of  Eustachian  tube. 

5,  Cartilaginous  portion  of  Eustachian  tube. 

6,  Pharyngeal  opening  of  Eustachian  tube. 

7,  Fossa  of  Rosenmiiller. 
Hard  Palate :  posterior  nasal  spine. 

9,  Internal  pterygoid  plate  :  haraular  process. 

10,  Bristle  passed  through  E.  tube. 

11,  Hypophysis  cerebri. 

12,  Cerebral  artery. 

13,  Sinus  cavernosus. 

14,  Cavity  of  the  tympanum. 

15,  Deep  temporal  fascia. 

Kg.  13. — Diagrammatic  scheme  of  the  conduit  passing  from  the  throat  to  the  auricle,  showing 
some  of  the  muscles  concerned  in  maintaining  the  equilibrium  of  the  transmitting  apparatus. 
Drawn  at  the  author's  suggestion  by  Dr.  Robert  Barclay. 

place  during  the  acts  of  crying,  sobbing,  or  eructation,  when  air  is  ex- 
pelled from  the  lungs  in  an  explosive  manner,  and  is  sent  up  into 
the  naso-pharyngeal  vault  with  much  energy.  In  yawning,  a  free  ad- 
mission of  air  also  occurs,  since  the  action  of  the  pharyngo-palatal 
muscles  then  opens  the  Eustachian  tube  freely. 

Deglutition  also  most  effectively  aids  in  this  function.     During 
this  act  the  pharyngeal  constrictors  come  nearly  together,  while  ten- 


RELATIONS  OF   THE    NASO-PHA.RYNX.  47 

sor  and  levator  muscles  raise  and  make  tense  the  soft  palate,  the 
uvula  filling  up  the  slight  interval  between  the  constrictors.  The 
swallowing  of  every  particle  of  food  and  drink,  or  accumulations  of 
mucous  secretions,  gives  rise  to  these  phenomena.  The  walls  of  the 
pharynx  are  not  only  narrowed  laterally,  but  are  also  shortened  ver- 
tically in  this  way,  and  the  mouth  of  the  Eustachian  tube  being  ele- 
vated, more  especially  by  the  contraction  of  the  peristaphylinus  mus- 
cle, is  dilated  as  well  as  the  fibro-cartilaginous  part  of  the  tube. 
There  is  an  upward  movement  of  the  fascia  of  the  pharynx  during 
deglutition  which  can  be  especially  well  seen  in  thin  subjects  during 
contraction  of  the  palato-pharyngei.  The  condensed  air  in  its  transit 
through  the  Eustachian  tube  to  the  ear-drum,  it  will  thus  be  seen,  is 
much  facilitated  by  the  action  of  the  constrictor  muscles. 

The  tensor  and  levator  palati  muscles  (see  Fig.  11,  from  Gray)  are  of 
sufficient  importance  in  this  connection  to  require  a  more  particular 
description  than  is  usually  given,  since  they,  in  connection  with  the 
tensor  tympani,  are  intimately  associated  with  the  performance  of 
the  function  under  consideration. 

The  tensor  palati,  also  known  as  the  Circumjlexus  palati,  sphenosal- 
pingo-staphylinus,pterystaphylinus  externus  (of  Riolanus),  perista- 
phylimis  externus  (of  Cruveilhier),  and  splienostapliylinus  (of  Win- 
slow),  is,  according  to  Hyrtl,  ^  a  flattened  muscle  which  arises  from 
the  spina  angularis  of  the  sphenoid  bone  and  from  the  cartilage  of 
the  Eustachian  tube,  passes  with  a  broad  tendon  around  the  hamular 
process  of  the  pterygoid  to  form  conjointly'the  broad  aponeurosis  of 
the  soft  palate.  Acording  to  Henle,-  it  also  has  fibres  of  origin  from 
the  neighboring  under  surface  of  the  temporal  wing  and  from  the 
shallow  fossa  at  the  base  of  the  median  plate  of  the  pharyngeal  wing. 
Its  fibres  are  "  attached  in  front  to  the  transverse  ridge  on  the  hori- 
zontal portion  of  the  palate  bone"  (Gray).^ 

The  levator  veil  palatini  muscle,  or  levator  palati,*'  arises  from  the 
under  surface  of  the  petrous  bone  in  front  of  the  carotid  canal,  and 
also  from  the  cartilage  of  the  Eustachian  tube,  and  sends  fibres  which 
blend  with  the  soft  palate.  The  tensor  palati  is  supplied  with  a 
nerve  from  the  otic  ganglion,  the  levator  palati  by  a  branch  from  the 

1  Anatomie,  page  645. 

^Anatomie,  vol.  2,  page  121. 

^  Henry  Gray.  Anatomy,  Descriptive  and  Surgical.  Phila.,  1878,  page 
369. 

*  Also  named  :  Petrosalpingostaphylinus,  Petrostaphylinus  (Chaussier), 
Pterygostaphylinus  internus  (Valsalva),  Pterystaphylinus  internus  (Riolan.), 
Peristaphylinus  internus  (Cruveilhier). — See  Henle's  Handbuch,  Vol.  2,  p. 
123,  1873. 


48  RELATIONS  OF  THE  NASCVPHARYKX. 

facial,  "  through  the  connection  of  its  trunk  with  the  Vidian,  by  the 
petrosal  nerves  "  (Gray).  The  connection  between  the  tensor  palati 
and  tensor  tympani  muscles  is  also  of  much  significance  here,  since 
their  fibres  are  often  intimately  blended,  as  may  be  seen  in  Fig.  13, 
and  their  aponeurotic  connection  along  the  Eustachian  tube  always 
exists,  suggesting  possibly  that  they  have  no  action  altogether  inde- 
pendently of  each  other.  Although  almost  invariably  described 
as  separate  and  distinct  muscles,  they  may  with  advantage  be  con- 
sidered together  when  discussing  their  functions.  Viewed  in  this 
manner  their  action  is  as  follows  :  During  expiration,  deglutition, 
etc.,  when  the  palate  is  elevated  by  the  tensor  palati,  the  membrana 
tympani  is  retracted  towards  the  inner  wall  of  the  tympanum  by  the 
tensor  tympani.  The  effect  of  contractions  of  the  tensor  tympani 
would  be,  therefore,  to  assist  in  elevating  and  opening  the  Eustachian 
tube  for  the  admission  of  air  and,  at  the  same  time,  preventing  the 
current  from  forcing  the  membrana  tympani  unduly  outwards,  and 
thus  interfering  with  the  equilibrium  of  auditory  tension. 

Where  the  transmitting  mechanism  of  the  ear  is  in  such  an  abnor- 
mal state  that  oscillations  of  the  drum-head  extend  beyond  the  normal 
range,  the  author  has  often  observed  that  the  entrance  of  air  into  the 
drum  in  excess  of  its  requirements  produces  cerebral  shock.  This 
may  be  due  to  excursions  of  unusual  amplitude,  inducing  shock 
through  impact  of  the  stapes,  or  to  the  pressure  upon  the  round  win- 
dow. It  thus  appears  that  the  constrictor  muscles  of  the  pharynx  are 
not  concerned  in  deglutition  only,  but  that  they,  with  the  assistance 
of  the  palatal  muscles,  control  the  movement  of  air  in  the  upper  air- 
tract. 

These  interior  muscles  have  a  correspondingly  close  and  important 
relationship  to  the  mucous  membrane  of  the  drum.  Eustachian  tube, 
and  phai-ynx,  through  the  underlying  fascia,  that  is  borne  by  the  ex- 
terior muscles  dominating  the  dermic  layer  and  superficial  fascia  of 
the  outer  parts  of  the  ear,  as  already  described.  In  the  combined 
action  of  the  interior  and  exterior  muscles  on  the  transmitting  mech- 
anism of  the  drum  is  seen  a  wonderful  adaptation  to  the  production 
of  needed  results. 

The  modus  operandi  of  the  mechanism  of  tlie  ear  has  long  been 
more  or  less  of  a  puzzle  to  physiologists,  especially  the  question  of 
the  maintenance  of  equilibrium.  This  latter  point  has  enjoyed  the 
attention  of  no  less  an  authority  than  Helmholtz,  whose  studies  of 
the  mechanism  of  the  ossicles  are  of  the  greatest  interest.  The  sugges- 
tion of  this  author,  however,  that  tension  depends  on  the  'tightness" 
of  ligaments  further  increased  by  the  "  elastic  tension ''  of  the  tensor 


RKLATIONS    OF    THE    NASOPHARYNX.  49 

tympani  muscle,  which  is  very  yielding,  "yet  always  slightly  stretched '' 
— and  "  whose  tension,  besides,  is  variable  and  can  be  adapted  to  the 
requirements  of  the  case"  '  — is  misleading,  since  it  is  a  physical  im- 
possibility for  a  muscle  to  remain  constantly  in  a  state  of  tension.  It 
is  true,  however,  that  the  ossicles  are  fixed  as  described  by  Helmholtz, 
the  handle  of  the  hammer  maintaining  the  indrawn  plane.  But  the 
writer  is  constrained  lo  believe  that  the  auricle  and  outward  parts  of 
the  ear,  the  skin  muscles,  fascia,  etc.,  are  the  principal  means  which 
keep  up  the  outward  tension,  and  through  which,  as  often  as  the 
membrane  is  driven  in  by  vibratory  movements  from  without,  its  re- 
turn to  a  state  of  rest  is  assured. 

These  conclusions  have  often  been  verified  by  the  study  of  the  action 
of  these  structures  in.  individuals  possessing  in  an  unusual  degree  vol- 
untary control  over  them,  as  may  be  seen  in  the  instances  to  be  pres- 
ently cited.  And  further  confirmation  is  to  be  found  in  observations 
in  cases  where  disease  has  left  the  drum-head  in  that  abnormal  state 
known  as  manometric,  i.  e.,  where  a  cure  has  been  effected  in  perfora- 
tive inflammation  through  closure  by  a  reproduction  of  the  dermic 
layer  only,  which  is  much  thinner  and  far  more  distensible  than  nor- 
mal membrane.     Examples  of  these  will  also  be  given. 

The  following  are  examples  of  remarkable  voluntary  control  of  the 
pharyngo-palatal  muscles  : 

Case  1. — Master  A.,  14  years  of  age,  came  to  the  author  on  ac- 
count of  a  catarrhal  condition  of  the  upper  air-passages  which  in- 
volved the  ear-drums,  but  had  given  rise  as  yet  to  only  a  very  slight 
amount  of  deafness.  He  is  of  slender  build,  tall  for  his  age,  and  the 
muscular  movements  generally  are  very  free,  especially  those  connected 
with  the  ear.  By  a  slight  voluntary  effort  he  can  contract  the  tensor 
palaii  and  tensor  tympani  muscles.  The  ability  to  thus  bring  these 
muscles  into  action,  a  function  usually  involuntarily  performed  along 
with  the  pharyngeal  constrictors  only,  was  discovered  quite  accident- 
ally. AVhen  he  produced  a  humming  noise  with  the  mouth  closed, 
he  discovered  that  the  effort  involved  the  palato-pharyngeal  muscles 
in  such  a  way  that  the  humming  was  very  loud  as  heard  by  himself, 
and  he  was  surprised  on  practising  in  this  way  in  the  school-room 
that  the  noise  was  not  observed  by  others.  When  this  curious  experi- 
ment was  made  out  of  doors,  street  sounds  seemed  distant  and  muffled. 
He  was  amused  very  much  to  thus  experience  deafness  one  moment 
and  the  next  to  hear  the  loud  clatter  and  roar  of  street  sounds,  as 
he  alternateh''  contracted  and  relaxed  the  muscles  dominating  the 
tension  of  the  drum-heads  from  within.  The  autophonous  phenomena 
lasted  while  he  kept  up  the  contractions,  and  besides  his  own  voice, 

'  The  Mechanism  of  the  Ossicles  and  Membrana  Tympani.      Prof.  Helm- 
holtz,    Trans,   by  James  Hinton.     The  New  Sydenham  Society.     London, 
1874,  pp.  121, 122,  130. 
4 


50  RELATIONS   OF    THE    NaSO-PH ARYNX. 

respiratory  sounds  and  the  rushing  and  gurgling  of  the  blood  in  the 
neighboring  arteries  could  be  heard.  A  gentle  murmur  "like  a  sea 
shell "  was  also  distinguishable.  Rhinoscopic  inspection  showed  that 
the  entire  integumentary  wall  of  the  pharynx  was,  with  great  facility, 
carried  upward  by  the  underlying  fascia  during  the  performance,  drop- 
ping down  again  when  relaxation  occurred.  The  contractions  could 
be  made  with  great  rapidity — as  frequently,  in  fact,  as  once  every 
second,  but  more  slowly  if  it  was  desired.  The  exercise  tired  the  pa- 
tient finally  if  long  continued,  and  subsequent  trials  required  greater 
effort.  The  patient  could  never  learn  to  hawk.  By  means  of  the  di- 
agnostic tube  connecting  their  ears,  the  writer  could  distinctly  hear 
a  soft  click  or  thud  in  the  tympanum  of  the  patient  whenever  the 
contractions  took  place.  The  act  of  gaping  during  these  contractions 
increased  the  tension  very  much  and  all  of  the  subjective  phenomena 
were  more  pronounced.  He  has  possessed  this  curious  faculty  for  a 
long  time,  and  practice  has  made  it  much  more  easy  of  execution. 
The  patient's  father,  a  medical  man,  has  also  the  power  of  voluntarily 
moving  these  muscles  in  an  unusual  degree,  and  during  the  act  much 
roaring  in  the  ears  is  experienced. 

The  author  finds  upon  his  records  many  cases  similar  to  the  fore- 
going, one  of  which  has  been  already  given  (Case  3,  p.  33) ;  though  space 
is  wanting  for  others  it  is  believed  that  the  above  are  sufficiently  illus- 
trative of  the  point  in  view.  The  study  of  the  performance  of  the 
function  of  intra-tympanic  air-renewal  from  a  pathological  point  of 
view  seems  also  to  confirm  the  views  advanced.  Many  opportunities 
for  this  present  themselves  where  the  transmitting  mechanism  has 
lost  its  tension  from  disease.  The  very  frequent  presence  of  mano- 
metric  cicatrices  of  the  drum-head  greatly  facilitates  observations  in 
this  direction,  and  the  anomaly,  moreover,  when  carefully  sought,  will 
be  more  frequently  found  than  many  suppose,  since  the  drum-head 
in  destructive  suppurative  processes  is  liable  to  undergo  reparation  in 
this  manner. 

The  following  cases  have  been  selected: 

Case  2. — Patient,  male,  60  years  of  age,  is  the  subject  of  long-stand- 
ing catarrhal  inflammation  of  the  middle  ears,  the  drum-heads  show- 
ing extensive  nutritive  changes.  He  has  constant  tinnitus  in  the  ears 
like  singing,  and  when  gaping  this  changes  to  a  sound  resembling  the 
ringing  of  a  bell  of  high  pitch,  especially  in  the  left  ear.  A  similar 
experience  occurs  if  the  left  auricle  is  smartly  tapped  with  the  fingers. 
When  the  cartilaginous  canal  of  the  left  ear  is  pushed  inward  the 
voice  is  autophonous. 

Case  3. — Male,  28  years  of  age.  The  drum-heads  have  a  humid  ap- 
pearance, due  to  chronic  catarrhal  inflammation  ;  the  left  is  greatly 
relaxed,  and,  on  Valsalvan  experiment  being  made,  becomes  very 
convex.  For  twelve  years  he  has  experienced  autophonia  in  this  ear. 
At  first,  tightly  stopping  the  meatus  with  a  wad  of  cotton-wool  over 


KELATIONS    OF    THE    NASO-PflARYNX.  51 

night  would  often  prevent  recurrence  of  this  phenomenon  tlie  fol- 
lowing day,  but  of  late  this  has  failed  to  be  of  any  service.  Hearing 
the  transmitted  heart  pulsations  autophonously  has  given  him  much 
anxiety,  and  this  has  been  the  cause  of  treatment  directed  to  supposed 
cardiac  disease.  Autophonia  ceases  while  the  tensor  paiati  and  tensor 
tympani  muscles  are  in  a  state  of  voluntary  contraction,  and  when 
the  patient  assumes  a  horizontal  position. 

Case  4. — Male,  38  years  of  age.  Has  chronic  catarrhal  inflamma- 
tion of  the  drums,  with  decided  trophic  changes  in  both  membranes. 
He  is  subject  to  autophonia  which  gives  rise  to  great  distress  during 
the  act  of  swallowing  food,  when  it  is  much  increased.  With  each 
act  of  mastication  there  is  an  oscillation  of  the  drum  membranes,  giv- 
ing rise  to  a  sensation  resembling  the  metallic  vibration  produced  by 
springing  in  and  out  the  bottom  of  a  tin  pail.  Blowing  the  nose 
forces  out  the  drum-head  and  ''stops  up  the  ears." 

Case  5. — Female,  33  years  of  age.  Has  manometric  cicatrices. 
She  has  the  power  of  contracting  voluntarily  the  tensor  paiati  and 
tensor  tympani  muscles  and  thus  improving  hearing.  Traction  upon 
the  auricle  has  the  same  etfect,  i.  e.,  restores  auditory  tension.  In 
this  case  tension  in  either  direction  seems  to  restore  equilibrium. 

Case  G. — Male,  63  years  of  age.  Has  chronic  catarrhal  inflam- 
mation of  the  middle  ears  with  relaxed  membranes.  Patient  suffers 
from  autophonia  with  a  constant  sensation  of  "thickness"  in  the 
•ears,  which  is  relieved  by  eructations.  Eather  prolonged  Valsalvan 
efforts,  however,  increase  the  unpleasant  symptoms  for  a  time.  In- 
flation with  the  air-bag  causes  the  explosive  sound,  and  increases 
temporarily  the  deafness.  Traction  upon  the  auricle  improves  hear- 
ing. 

Case  7. — Female,  22  years  of  age.  She  can  voluntarily  produce 
movements  of  the  auricle,  the  action  being  accompanied  by  a  sense  of 
something  moving  "inside  her  face."  She  can  also  voluntarily  con- 
tract the  tensor  paiati  and  tensor  tympani  muscles,  and  during  the 
act  all  extraneous  sounds  seem  to  come  from  a  distance,  and  a 
"  vacuum"  or  feeling  of  "  numbness  "  is  felt  about  the  ears.  It  will 
be  observed  that  the  effect  of  the  tension  thus  made  upon  the 
membrana  tympani  ^  was  to  ."  damp  "  or  "  muffle  "  the  transmitting 
mechanism. 

Case  8. — Male,  26  years  of  age.  Has  chronic  catarrhal  inflamma- 
tion of  the  middle  ear  with  a  large  manometric  cicatrix  in  the  right 
membrana  tympani.  The  latter  is  bulged  out  on  swallowing  or  on 
performing  the  Valsalvan  experiment,  giving  rise  to  autophonia. 
Patient  possesses  the  power  to  voluntarily  retract  the  membrana 
tympani  by  means  of  the  intrinsic  tensor  muscles,  on  which  the 
autophonia  disappears. 

Case  9. — Male,  20  years  old,  with  chronic  catarrhal  inflammation 
of  the  drums.  The  membranes  are  humid  in  appearance  and  have 
manometric  cicatrices.     Swallowing  and  the  Valsalvan  experiment 


52  RELATIONS    OF   THE    NASO-PHAEYNX. 

cause  crackling  sounds  in  the  left  ear.  He  experiences  autophonia 
much  of  the  time,  during  which  all  extraneous  sounds  heard  seem  to 
be  ''muffled/'  and  his  own  voice,  on  entering  the  ear  from  within, 
appears  to  be  projected  "against  a  cloth."  He  can  nearly  always 
relieve  the  autophonia  by  traction  on  the  tragus.  The  "clouded'' 
feeling,  always  existing  in  the  ears,  causes  him  to  perform  the  act  of 
swallowing  or  yawning  very  frequently.  During  the  act  of  swallow- 
ing, if  the  otoscopic  tube  be  employed,  the  soft  gliding  motion  of  the 
tensor  tympani  muscle  can  be  heard,  and  if  the  Valsalvan  experiment 
is  done,  the  membrana  tympani  can  be  heard  to  bulge  outwardly  with 
a  "thud." 

Case  10. — Female,  24  years  of  age.  Has  manometric  cicatrices  of 
both  membranes.  Hears  only  loudest  voice  in  one  ear  and  loud  in. 
the  other.  Hearing  improves  very  much  after  blowing  the  nose,  or 
by  making  traction  on  the  auricle  with  a  finger  placed  in  the  concha. 
After  Valsalvan  experiment,  the  drum-heads  are  heard  to  return  to 
their  usual  position  with  a  "  snap." 

Case  11. — Male,  21  years  of  age.  Both  membranes  have  mano- 
metric cicatrices,  due  to  ear-boxing,  on  both  sides.  Hearing  is  very 
good  unless  autophonia  exists;  the  frequent  recurrence  of  ths  phe- 
nomenon, however,  gives  rise  to  variable  hearing,  and  when  aural 
catarrh  is  present,  this  is  more  marked.  Usually  the  distress  is  easily 
relieved  by  slight  voluntary  contraction  of  the  tensor  palati  and  tensor 
tympani  muscles,  pulling  the  auricle  outwardly  or  moving  the  jaws  as 
in  mastication.  Valsalvan  experiment  bulges  out  the  membranae  and 
increases  the  trouble. 

A  study  of  the  above  phenomena  occurring  in  advanced  stages  of 
chronic  catarrhal  inflammation  of  the  middle  ear,  attended  with  atro- 
phy of  the  mucous  lining,  and  perhaps  other  changes,  together  with  a 
relaxed  drum-head  and  deafness,  will  be  found,  it  is  hoped,  exceedingly 
instructive  in  this  connection.  In  looking  over  the  notes  of  a  large 
number  of  these  cases,  the  writer  finds  numerous  other  examples, 
among  which  the  following  are  more  important: 

In  a  number  of  instances  the  recurrence  of  head  catarrh,  accompa- 
nied by  increased  mucous  secretion,  improved  hearing  very  much 
while  the  exacerbation  continued;  and  in  many  instances  "crack- 
ling" or  "cracking,"  or  "stopping  up  with  air  bubbles,"  or  "shut- 
ting up,"  or  "closing  the  ear"  occurred  on  swallowing,  sneezing, 
yawning,  hiccoughing,  or  moving  the  jaw  as  in  mastication;  in  all  of 
them  there  was  an  increase  of  deafness  for  a  longer  or  shorter  period 
of  time.  On  the  other  hand,  an  equally  large  number  of  patients 
found  that  the  very  same  phenomena  caused  better  hearing  tempo" 
rarily.  These  experiences  are  a  constant  source  of  great  annoyance 
to  the  patient  when  eating  or  conversing.  In  one  case,  where  there 
was  a  perforation  of  the  left  drum-head,  during  the  first  act  of  swal- 


RELATIONS    OF   THE    NA80-PHARYNX.  53 

wing,  the  "ear  was  closed  to  hearing,"  hut  the  second  act  ''cleared 
it  up  again/' 

A  very  interesting  case  was  one  where  the  drua(-lieads  were  much 
relaxed,  and  the  Valsalvan  experiment,  or  swallowing,  bulged  them 
out;  on  yawning,  the  left  membrane  was  first  bulged  outwardly, 
"opening"  tiie  ear,  and  retraction  or  collapse  immediately  following, 
'' closed ''  the  ear  to  hearing.  The  interference  with  tension  of 
the  transmitting  mechanism  which  tunnel-workers  under  high  atmo 
spheric  pressure  often  experience,  is  a  practical  illustration  of  the 
importance  of  keeping  in  mind  the  conditions  under  which  auditory 
equilibrium  is  maintained,  and  even  in  mild  catarrhal  attacks  of  the 
upper  air-tract,  closure  of  the  Eustachian  tube  to  a  slight  extent 
only  is  very  often  sufficient  to  interfere  with  the  performance  of 
the  functions  of  these  parts.  The  writer  has  frequently  observed 
that  persons  having  defective  ear-drums  acquire,  almost  uncon- 
sciously, the  habit  of  adjusting  auditory  tension  by  resorting  to  some 
of  the  expedients  mentioned  above.  Equilibrium  may  thus  be 
established  by  tractile  force  applied  from  without,  as  by  movements 
of  the  inferior  maxillary,  which  affect  tension  by  pressure  of  the 
partially  displaced  coronoid  process  upon  the  cartilaginous  portion  of 
the  external  auditory  canal;  or  by  traction  upon  some  portion  of  the 
auricle.  On  the  other  hand,  the  desired  result  is  brought  about  by 
muscular  force  exerted  from  the  pharynx,  as  in  snuffing  in  air,  swal- 
lowing, sighing,  yawning,  and  the  like. 


ClIAPTEE    lY. 

THE    SENSE   OF   HEARING. 

The  perception  of  sound,  which  constitutes  audition  in  man  and 
the  higher  forms  of  air-breathing  animals,  is  similar  to  the  sense  of 
touch  which  seems  to  be  the  only  medium  of  hearing  in  some  of  the 
lower  forms  of  life.  Impulses  of  air,  indeed,  may  be  perceived  by 
man  when  received  upon  the  cutaneous  surface,  specially  the  shock 
from  the  discharge  of  great  guns  and  other  violent  explosions  if  near. 
Advantage  is  taken  of  this  fact  in  communicating  with  the  deaf,  a 
remarkable  instance  of  which  was  related  to  the  writer  by  Prof.  A. 
Graham  Bell:  the  case  being  that  of  his  mother  who  is  deaf  to  ordi- 
nary conversation,  but  takes  cognizance  of  sound  when  Prof.  Bell 
places  his  lips  in  contact  with  one  of  her  eyes  while  speaking.  A 
similar  instance  to  the  above  was  reported  many  years  ago  in  the 
American  Journal  of  Medical  Sciences  by  the  late  Prof.  Muzzy,  where 
a  deaf  boy  could  apparently  hear  best  through  the  back  part  of  the 
head. 

The  highly  specialized  function  of  hearing  in  man  requires  for  its 
performance  the  oscillating  expansion  of  the  skin,  known  as  the 
drum-head,  which  vibrates  free  in  equilibrio  when  agitated.  The 
performance  of  the  function  of  hearing  consists  (1)  in  the  collec- 
tion of  sound  by  the  auricle  and  external  auditory  canal;  (2)  its 
transmission  by  the  conductive  mechanism  to  the  middle  ear  to  (3) 
the  nervous  apparatus  of  the  inner  ear,  and  finally  its  impression  upon 
(4)  the  perceptive  centre  of  the  brain. 

Tlie  perception  of  sound.  Since  the  phonograph  of  Edison  and  the 
telephone  of  Bell  have  made  familiar  the  behavior  of  sound  in  its 
relations  to  the  ear,  so  far  as  actual  transmission  to  the  inner  ear  is 
concerned,  the  field  of  speculation  now  seems  mainly  limited  to  the 
functions  of  the  nervous  apparatus. 

Hearing  takes  place  through  the  motion  imparted  to  the  auditory 
apparatus  by  the  movements  of  sound.  Excursive  movements  of  the 
drum-head  having  been  first  induced,  the  impulses  of  sound  are  trans- 


THE    SENSE    OF    HEARING.  55 

mitted  through  the  chain  of  ossicles —the  malleus,  incus,  and  stapes — 
to  the  inner  ear,  giving  rise  to  aqueous  vibrations  in  the  semicircular 
canals  and  the  superior  scala  (or  scali  vestibuli)  of  the  cochlea.  The 
membrana  tympani  secundaria  (or  membrana  fenestrse  rotundae), 
responding  to  vibrations  which  are  unimpeded  by  the  drum-head, 
communicates  them  to  the  fluid  inclosed  in  the  inferior  scala  (or  scala 
tympani)  of  the  cochlea.  The  several  branches  of  the  auditory  nerve 
are  thus  simultaneously  influenced  by  the  various  sounds  of  which  the 
perceptive  centre  is  capable  of  taking  cognizance. 

The  terminal  filaments  of  the  nerve  of  hearing  distributed  in  the 
inner  ear  possess  the  function  of  taking  up  the  sounds  transmitted  from 
without,  their  tension  being  adapted  to  receiving  and  transmitting  im- 
pressions of  which  sound  is  composed.  If  it  be  permitted  to  thus 
briefly  formulate  a  hypothesis  of  the  modus  operandi  of  a  nervous  ap- 
paratus, apparently  so  complicated  when  viewed  in  the  light  of  existing 
knowledge,  in  lieu  of  other  conjectures  (since  an  exhaustive  review 
of  the  subject  would  be  out  of  place  here),  this  inference  may  be 
made  :  that  the  different  surfaces  of  the  sentient  region  of  the  scalae 
of  the  cochlea  and  of  the  semicircular  canals,  when  influenced  (ex- 
cited) by  sounds  of  various  pitch  and  loudness,  are  adapted  to  impart- 
ing (transmitting)  them  to  the  perceptive  centre.  That  the  auditory 
nerve  possesses  the  seemingly  complex  function  of  transmitting  a 
large  number  of  sound  impressions  received  from  without  at  the 
same  moment  may  be  inferred  from  an  understanding  of  analogous 
and  demonstrable  phenomena  in  physics,  as,  for  example,  the  elec- 
trical transmission  of  multiple  messages  simultaneously  through  a 
single  wire,  or  the  well-known  action  of  the  transmission  in  telepho- 
nic communications  of  speech.  By  the  latter  it  is  proven  that  all 
tones,  however  complex,  are  transmissible  without  any  so-called  ner- 
vous analysis  ;  and  by  means  of  the  phonograph  they  may  even  be 
permanently  impressed  upon  a  metallic  surface  to  be  given  off  again 
without  change  in  the  form  of  sound  vibrations. 

The  writer  has  long  been  of  the  belief  that  the  accepted  theories  of 
audition,  in  respect  to  certain  important  anatomical  and  physiological 
dogmas  as  set  forth  with  such  distinguished  ability  by  Hemholtz, 
asd  to  which  allusion  has  been  above  made,  are  faulty,  and  the 
views  thus  held  for  the  past  ten  or  twelve  years,  and  set  forth  in  pub- 
lications from  time  to  time,  especially  in  a  paper  prepared  for  the 
American  Otological  Society,'  have  gained  strength  from  subsequent 
observations.  Other  writers  have  also  begun  to  express  doubts  in 
respect  to  the  soundness  of  the  generally  accepted  views  on  this  snb- 

'  Trans.  American  Otological  Society,  1878. 


56  THE   SENSE    OF    IIEARIXG. 

ject,  and  those  of  Prof.  Eutherford,'  given  in  a  lecture  delivered 
before  the  British  Association,  are  so  much  to  the  point  that  his  con- 
clusions are  here  quoted  at  length. 

He  pays  this  tribute  to  Helmholtz  which  the  present  writer  fully 
indorses  : 

'•  This  theory  of  sound-sensation,  then,  is  so  full  of  difficulty  when 
applied  to  the  peripheral  mechanism  in  the  ear,  and  so  unsatisfactory 
when  we  pursue  it  into  the  brain,  and  it  seems  so  hopeless  to  adapt  it 
to  the  facts,  that  I  think  it  must  be  abandoned.  But  before  I  pro- 
pose another  theory,  I  would  pay  a  humble  but  sincere  tribute  to  the 
genius  of  Helmholtz.  His  magnificent  services  to  science  have  long 
since  placed  his  name  amongst  those  of  the  immortals.  His  theory 
of  sound-sensation  may  be  faulty,  but  that  can  never  tarnish  the 
splendor  of  his  many  wonderful  contributions  to  the  progress  of 
scientific  knowledge." 

In  referring  to  the  sense  of  hearing  Prof.  E.  says  : 

*'  Some  five  years  ago  it  struck  me  that  the  case  of  the  telephone  may 
throw  light  on  these  difficulties  regarding  the  sense  of  hearing.  In 
the  telephone  there  is  a  thin  plate  of  iron  placed  near  the  end  of  a 
permanent  steel  magnet.  A  bobbin  of  thin  copper  wire  is  coiled 
round  the  end  of  the  magnet  nearest  the  plate,  and  is  connected 
with  a  bobbin  of  -^vire  around  the  magnet  of  a  second  telephone 
in  every  respect  similar  to  the  first.  When  sound-waves  fall  on  the 
plate  of  the  transmitting  telephone  it  vibrates.  The  vibrations  of  the 
iron  near  the  magnet  affect  the  magnetism,  and  so  induce  in  the  wire 
currents  of  electricity  whose  frequency  and  amplitude  correspond  to 
those  of  the  vibrations  of  the  iron  plate  induced  by  the  sound.  The 
currents  travel  to  the  receiving  telephone  and  induce  oscillations  of 
its  magnetism,  which  in  turn  cause  its  iron  plate  to  vibrate  and  pro- 
dace  sounds  similar  to  those  comm,unicated  to  the  first  telephone. 
There  is  no  analysis  of  the  sound-waves.  The  transmitting  telephone 
takes  up  simple  or  complex  vibrations.  The  harmonies  of  an  orches- 
tra may  fall  upon  it,  and  it  does  not  fail  to  convert  the  complex 
sound-vibrations  into  electrical  vibrations,  and  these  again  into  the 
complex  sound  of  the  orchestra  in  the  receiving  telephone.  It  is,  in- 
deed, one  of  the  most  wonderful  inventions  of  recent  times.  Can  it 
throw  light  on  the  sense  of  hearing  ? 

"  The  theory  which  I  have  to  propose  may  be  termed  the  Telephone 
Theory  of  the  Sense  of  Hearing.  The  theory  is  that  the  cochlea 
does  not  act  on  tha  principle  of  sympathetic  vibration,  but  that  the 

'  A  Lecture  on  the  Sense  of  Hearing.  William  Rutherford.  The  Lancet, 
January  let,  1887. 


THE    SENSE    OF    HEARING.  57 

hairs  of  all  its  auditory  cells  vibrate  to  every  tone,  just  as  the  drum 
of  the  ear  does  ;  that  there  is  no  analysis  of  complex  vibrations  in  the 
<30chlea  or  elsewhere  in  the  peripheral  mechanism  of  the  ear  ;  that 
the  hair  cells  transform  sound-vibrations  into  nerve-vibrations  similar 
in  frequency  and  amplitude  to  the  sound-vibrations  ;  that  simple  and 
complex  vibrations  of  nerve-molecules  arrive  in  the  sensory  cells  of 
the  brain,  and  there  produce,  not  sound  again  of  course,  but  the  sen- 
sations of  sound,  the  nature  of  which  depends  not  upon  the  stimula- 
tion of  diiferent  sensory  cells,  but  on  the  frequency,  amplitude,  and 
form  of  the  vibrations  coming  into  the  cells,  probably  through  all  the 
fibres  of  the  auditory  nerve.  On  such  a  theory  the  physical  cause  of 
harmony  and  discord  is  carried  into  the  brain,  and  the  mathematical 
principles  of  acoustics  find  an  entrance  into  the  obscure  region  of  con- 
sciousness. Now  if  nerve  energy  were  only  electricity,  that  theory 
would  probably  be  accepted  at  once.  But  nerve  motion  is  very  slug- 
gish when  compared  with  electricity. 

"  I  have  kept  this  theory  back  for  five  years,  because  I  felt  I  had  no 
evidence  of  the  possibility  of  sending  a  rapid  succession  of  vibrations 
along  a  nerve.  It  cost  me  a  good  deal  of  thought  and  experimental 
observation  to  find  the  evidence  I  required.  If  we  give  to  a  motor 
nerve  of  a  frog  or  rabbit  10  instantaneous  shocks  of  induced  elec- 
tricity in  a  second,  10  impulses  will  pass  along  the  nerve  to  the 
muscle,  and  produce  10  distinct  contractions  in  the  same  period. 
If  we  send  40  impulses  along  the  nerve,  we  get,  not  40  contrac- 
tions of  the  muscle,  but  a  single  continuous  contraction,  because  the 
several  contractions  are  fused  together.  Now,  if  we  listen  to  the 
muscle  so  stimulated,  we  hear  a  musical  note  having  the  pitch  of 
40  vibrations  per  second.  Each  sound-vibration  results  from  the 
sudden  shock  of  chemical  discharge  due  to  the  arrival  of  each  nerve 
impulse  in  the  muscular  substance.  If  we  stimulate  the  nerve,  say, 
200  times  per  second,  by  causing  a  tuning-fork  to  make  and  break 
the  primary  circuit  of  an  induction  machine,  and  so  send  200  shocks 
per  second  into  the  nerve,  the  pitch  of  the  note  in  the  muscle  exactly 
corresponds.  It  has  the  same  pitch  as  the  fork.  I  experimented  in 
this  way,  and  eventually  found  that  I  could  send  as  many  as  352  im- 
pulses per  second  along  the  nerve  of  a  rabbit  and  get  a  note  from  the 
muscle  of  the  pitch  of  352  vibrations  per  second — that  is,  a  note  of 
the  pitch  of  F  in  the  lowest  space  of  the  treble  clef.  But  when  I 
tried  by  more  rapid  stimulation  of  the  nerve  to  get  a  higher  note  from 
the  muscle,  I  failed  ;  there  was  nothing  but  a  noise  heard.  That  a 
low  rumbling  sound  is  produced  by  a  contracting  muscle  is  known  to 
every  physiologist.     You  can  hear  it  if  you   firmly  clench  the  jaws 


58  THE   SENSE   OF    HEARING. 

during  the  stillness  of  night,  when  other  sounds  are  hushed.  It  is  a 
sound  of  very  low  pitch  due  to  vibrations  certainly  below  forty — per- 
haps not  more  than  ten  or  twelve  per  second.  There  is,  therefore, 
nothing  new  in  my  statement  that  a  note  may  be  heard  in  a  muscle  ; 
the  new  point  is  that  the  pitch  of  the  note  may  be  increased  by  a  more 
rapid  stimulation  of  the  nerve,  and  that  as  many  as  352  impulses 
may  be  sent  along  a  nerve  and  retain  their  individuality  so  sharply 
that  they  can  produce  a  note  in  a  muscle  having  a  pitch  number  of 
352.  That  fact  will  give  support  to  a  vibrational  theory  of  nerve 
energy. 

"Now,  am  I  to  conclude  that,  because  I  failed  to  get  a  higher  note 
than  one  of  352  vibrations  from  the  muscle,  it  is  not  possible  to  send 
more  than  352  vibrations  per  second  along  a  nerve  ?  By  no  means  ; 
the  fibres  of  a  muscle  are  very  different  from  those  of  a  nerve,  and 
also  very  different  from  nerve  cells.  The  molecules  in  both  of  them 
can  probably  vibrate  far  more  rapidly  than  352  times  per  second. 

"  I  have  therefore  directly  proved  that  vibrations  of  the  same  fre- 
quency as  all  the  lower  tones  of  the  scale,  from  the  lower  F  of  the 
treble  clef  downwards,  can  be  transmitted  by  a  nerve.  A  short  time 
ago  it  occurred  to  me  that  the  note  produced  by  the  wing  of  an  insect 
furnishes  a  simpler  proof  of  the  possibility  of  transmitting  a  rapid 
series  of  impulses  along  a  nerve.  The  wing  of  the  humble-bee  pro- 
duces the  note  F  in  the  lowest  space  of  the  treble  clef.  It  gives,  there- 
fore, 352  complete  vibrations  in  a  second.  Every  downward  motion 
of  the  wing  doubtless  results  from  an  impulse  sent  along  the  nerve  to 
the  muscles  that  lowers  the  wing.  Therefore  we  may  conclude  that 
about  352  impulses  per  second  traverse  the  motor  nerves  of  the  hum- 
ble-bee's wing  during  flight.  In  the  honey-bee  the  note  of  the  wing 
is  A  in  the  treble  clef — that  is,  two  notes  higher  than  in  the  humble- 
bee,  so  that  460  impulses  appear  to  pass  along  its  motor  nerves  in  a 
second.  In  a  human  motor  nerve  the  impulses  transmitted  by  it 
during  voluntary  effort  are  not  more  than  10  or  12  per  second 
(Schaefer).  I  have  therefore  some  substantial  evidence  in  support  of 
my  theory  of  sound-sensation.  And  I  cannot  but  think  that  the  evi- 
dence in  favor  of  it  will  increase.  I  do  not  wish  you  to  suppose  that 
on  my  theory  of  hearing  difficulties  disappear  ;  far  from  it.  I  merely 
assert  that  the  difficulties  which  seem  insurmountable  on  the  theory 
of  Helmholtz  are  diminished  by  the  theory  which  I  have  submitted. 
Should  my  theory  of  the  sense  of  hearing  find  acceptance,  it  will  lead 
to  a  reconstitution  of  theories  regarding  the  other  sense  organs." 


PART    SECOND, 

CAUSES   OF  EAR  DISEASE. 


d 


CHAPTER    Y. 

Heredity.  Cachexia.  Age.  Occupation.  Defective  Personal  Hygiene.  Sy- 
philis. Acute  Infectious  Diseases:  Scarlet  Fever,  Measles,  Variola,  Diph- 
theria,  Cerebro-spinal  Meningitis,  Mumps,  Pertussis,  Typhoid,  "Roman," 
and  other  Fevers.    Cutaneous  Affections. 

It  is  a  trite,  but  nevertheless  important  saying,  that  violations  of 
the  laws  of  health  are  transmitted  to  the  offender's  offspring,  and,  in 
considering  the  causation  of  diseases  of  the  upper  air-tract,  heredity 
must  be  taken  into  account,  as  well  as  in  every  disease  to  which  man 
is  subject. 

Of  course,  the  more  important  and  more  frequently  met  with  caus- 
ative influences  only  can  be  considered  here,  and  space  will  not  ad- 
mit of  an  extended  notice  of  these. 

HEREDITY,  CACHEXIA,  ETC. 

Various  transmitted  constitutional  taints,  such  as  arise  from  con- 
sumption, syphilis,  gout,  etc.,  interfering  with  the  development  of 
the  individual,  and  also  the  physical  deterioration  found  in  the  off- 
spring of  intemperate  and  dystrophic  persons,  should  be  considered 
causative,  more  or  less,  of  many  aural  troubles.  Besides  the  physical 
defects  due  to  arrest  of  development  in  the  ears,  eyes,  teeth,  and 
other  organs,  and,  furthermore,  the  disease  of  the  glandular  struc- 
tures (strumous  habit)  among  such  progeny,  they  are  liable  to  be  ex- 
ceedingly neuropathic  and  susceptible  to  the  invasion  of  disease. 

The  records  of  the  author  also  show  a  large  number  of  instances 
where  ear  disease  was  disclosed  in  both  of  the  parents  and  some  or  all 
of  the  children.  In  one  family,  the  mother,  eight  of  her  children, 
and  an  aunt  were  suffering  at  the  same  time  with  purulent  catarrh  of 
the  middle  ear;  in  another,  both  parents  and  five  of  their  children 
were  likewise  affected  with  some  form  of  aural  catarrh.  To  find 
three  or  four  children  in  the  same  family  affected  in  this  manner  is 
quite  a  common  occurrence. 

The  possible  effect  of  influences  on  the  maternal  progenitor  are 


62  AGE.      OCCUPATION. 

worthy  of  consideration.  The  following  case  in  this  connection  is 
suggestive:  The  first-born  child  of  a  healthy,  well-developed,  and 
intelligent  woman  was,  when  six  months  of  age,  thought  to  be  deaf, 
since  she  could  only  hear  jarring  of  the  floor  and  the  like,  and  the 
sound  of  a  high-pitched  whistle  which  her  father  carried,  and  which 
seemed  to  become  quite  familiar  to  her  ears.  The  mother  had,  how- 
ever, during  the  first  month  of  pregnancy  an  attack  of  rubeola, 
and  was,  furthermore,  much  worried  during  the  entire  period  of 
gestation  about  her  husband,  who  was  very  nervous  and  becoming 
deaf  from  aural  catarrh.  When  the  writer  examined  this  child 
at  the  age  of  sixteen  months,  it  was  found  to  have  catarrh  of  the 
head  and  ears,  the  origin  of  which  may  have  been  embryonic. 
No  anatomical  malformation  of  the  ears  was  discovered  in  the  infant, 
nor  was  there  any  apparent  transmissible  organic  defect  in  the 
parents. 

AGE. 

To  judge  from  the  considerable  number  of  deaf-mutes  seen  where 
no  congenital  deformity  can  be  detected,  the  occurrence  of  pre- 
natal catarrh  is  probably  very  frequent.  A  dysthetic  condition  of 
the  foetus  giving  rise  to  the  development  of  head-catarrh  may  thus 
arise  from  syphilitic  taint  or  other  constitutional  cachexia  in  the 
parents.  The  foetus  is  likewise  affected  by  other  influences,  among 
which  the  exanthemata  deserve  especially  to  be  mentioned.  Whether 
the  early  development  of  tlie  deciduous  teeth  is  ever  active  enough  to 
cause  disturbance  will  require  considerable  research  to  determine; 
but  reflected  irritation  from  this  source  might  occur,  it  would  seem, 
since  there  are  instances  of  their  presence  at  birth,  or  very  early  ap- 
pearance after  this.  Protracted  labor  is  liable  to  be  attended  with 
injury  to  the  ear,  as  Von  Troeltsch  has  so  well  pointed  out  in  his 
admirable  work  on  "Diseases  of  the  Ear  in  Children." 

Purulent  catarrh  of  the  middle  ear  with  profuse  discharge  is  very 
much  more  frequent  in  infancy  and  youth,  while  atrophic  catarrh  is 
largely  a  disease  of  adult  and  middle  life.  As  the  adult  subject  ad- 
vances in  life,  the  effects  of  dystrophia  naturally  manifest  themselves 
as  progressive  aural  catarrh,  and  the  resulting  defectiveness  in  the 
transmitting  mechanism  of  the  middle  ear  gives  rise  to  forms  of 
ear  disease,  with  great  deafness. 

OCCUPATION. 

The  occupations  and  habits  of  people  have  much  to  do  with  the 
production  of  various  aural  complaints.     Those  exposed  in  their  work 


DEFECTIVE   PERSONAL    HYGIENE.  63 

to  atmospheric  changes,  to  damp  and  chilly,  likewise  to  overheated 
air,  in  dusty  and  dirty  shops,  are  much  more  prone  to  ear  disease, 
than  those  persons  working  in  better  and  more  healthy  surroundings. 
Among  the  first  should  be  mentioned  the  tunnel-workers  and  the 
drivers,  both  of  whom  are  constantly  subjected  to  great  atmospheric 
pressure  (see  Chapter  XIX.),  The  class  of  laborers  who  are  con- 
stantly exposed  to  loud,  sudden,  and  continued  noises,  as,  for  in- 
stance, boiler  makers,  engineers  on  railroads,  and  workmen  employed 
in  noisy  factories,  are  all  liable  to  experience  trouble  in  the  ears 
from  the  irritation  of  constant  aerial  impact  (see  Chapter  X.). 
Longshoremen,  dock-builders,  miners,  night  watchmen,  etc.,  are  es- 
pecially liable  to  ear  affections  due  to  out-door  vicissitudes.  The 
class  of  individuals,  furthermore,  which  includes  the  workers  in  to- 
bacco, tea,  and  coffee,  the  shop  girls  and  clerks  overworked  in  badly 
ventilated  shops,  telegraph  operators,  governesses,  waiters,  etc.,  are 
exposed  to  over-heating  and  dust,  and  will  be  found  to  suffer  from 
catarrh  of  the  upper  air-passages,  rendering  them  very  susceptible  to 
ear  diseases. 

DEFECTIVE  PEESONAL  HYGIENE. 

The  hygienic  feature  of  the  treatment  of  disease  is  too  important 
to  be  entirely  passed  over  in  silence  in  a  work  devoted  to  even  a  spe- 
cial department  in  medicine.  The  normal  state  of  man  in  this  con- 
nection may  be  regarded  as  one  in  which  he  can  best  adapt  himself 
to  the  vicissitudes  of  out-door  life  in  any  climate  in  which  he  may 
chance  to  live.  His  health  demands  that  the  usual  exercise  taken 
must  not  be  beyond  the  verge  of  moderate  fatigue,  nor  omitted  alto- 
gether in  either  very  warm  or  very  cold  weather.  Since  animal  heat 
is  derived  from  food,  the  latter  must  be  proportioned  to  the  quantity 
of  the  former  lost  through  escape  into  space  by  radiation,  which  is 
greater  in  cold  than  in  warm  weather. 

The  problem  of  maintaining  an  equilibrium  where  thermal  varia- 
tion is  great  is  one  of  difficult  solution,. especially  in  winter  weather; 
thus  exercise  is  impeded,  in  a  measure,  proportionately  to  the  means 
employed  in  retaining  bodily  heat  by  means  of  clothing,  etc.  If  the 
escape  of  heat  from  the  body  by  insensible  perspiration  is  prevented, 
in  addition  to  the  use  of  non-conducting  clothing,  by  impervious  rub- 
ber cloth,  the  skins  of  fur-bearing  animals,  and  the  like,  which  inter- 
fere with  evaporation,  the  clothing  becomes  saturated  with  moisture, 
an  exceedingly  unhealthful  and  disagreeable  condition.  The  in- 
judicious use  of  rubber  cloth  and  fur  garments   in  our   temperate 


64  SYPHILID.       SCARLET    FEVER. 

climate  is  therefore  greatly  to  be  deplored.  The  seductive  comfort  of 
the  sealskin  sacque  has  made  this  mantle  of  death  a  favorite  even  more 
than  its  handsome  appearance,  and  its  constant  use,  as  well  as  that  of 
fur  collars,  fur  trimmings,  and  boas  about  the  neck,  is  the  cause  of 
not  only  severe  pulmonary  disease,  but  of  head-colds  ending  in  per- 
sistent aural  and  nasal  catarrhs. 

These  ill-effects  are  due  to  the  greatly  increased  sensibility  which 
ensues  from  the  use  of  such  clothing,  often  combined  with  neglect 
of  out-door  exercise,  and  over-feeding.  In  the  writer's  experience, 
children  are  often  made  exceedingly  susceptible  to  colds  by  the  use  of 
superabundant,  though  handsome,  wraps  made  of  furs,  which  in  our 
climate  are  at  best  suitable  only  for  emergencies  arising  in  exception- 
ally cold  weather. 

Space  will  not  permit  of  extended  observation  on  this  topic,  but, 
in  conclusion,  the  writer  would  caution  against  attributing  bodily 
troubles  to  exterior  influences  alone,  since  nervous  strain,  improper 
feeding  and  the  like,  are  no  less  frequently  to  blame  than  the  forme. 

SYPHILIS. 

Affections  of  the  organ  of  hearing  in  the  primary  stage  of  syphili- 
tic infection  are  very  rare.  There  have  been,  however,  sbme  few 
cases  of  chancre  of  the  auricle  and  neighboring  parts  reported  by  dif- 
ferent authors.  It  is  in  the  secondary  stage  that  aural  affections  are 
most  frequently  met  with,  and  of  these  latter  the  rapidly  increasing 
or  sudden  deafness  with  more  or  less  distressing  tinnitus  aurium  form 
he  prominent  symptoms.  The  reader  may  consult  Chapter  XII. 
for  further  information  on  this  subject. 

ACUTE  INFECTIOUS  DISEASES. 

Scarlet  Fever.     Measles.    Variola.     Diphtheria.     Cerebro-spinal    Meningitis. 
Mumps.     Pertussis.     Typhoid  Fever.     "Roman,"  and  other  Fevers. 

The  exanthemata  form  by  far  the  most  important  among  the  above- 
named  group  of  diseases,  all  of  which  tend  so  much  to  the  production 
of  ear  troubles,  and  of  which  scarlet  fever  should  be  regarded  as  the 
most  prominent. 

The  ear  becomes  affected  in  scarlet  fever  by  immediate  invasion  of 
the  mucous  membrane  of  this  organ,  along  with  the  rest  of  the  upper 
air  tract.  A  poisoned  condition  of  the  blood  (uraemia,  pyaemia,  etc.) 
occurring  in  some  cases  may  also  be  regarded  as  remotely  causative. 
The  frequency  of  aural  disease  resulting  from  scarlatina  cannot  be 


MEASLES.  65 

estimated  with  accuracy,  since  many  cases  attributed  to  this  cause  by 
parents  are  found  on  inquiry  to  have  some  other  origin.  Burckhardt- 
Merian '  tabulated  four  thousand  three  hundred  and  nine  cases  of 
acquired  deaf-mutism,  four  hundred  and  forty-five  (or  10.32  per  cent) 
of  which  were  alleged  to  have  resulted  from  scarlet  fever. 

The  symptoms  of  acute  catarrhal  inflammation  of  the  middle  ear, 
occurring  during  the  course  of  a  severe  attack  of  scarlet  fever,  are  liable 
to  be  overlooked,  owing  to  the  gravity  of  other  manifestations  of  the 
disease,  and  any  aural  trouble  becoming  quiescent  on  recovery  may 
not  be  discovered  until  roused  into  activity  by  some  other  cause. 

Scarlet  fever  may  be  followed  by  mastoid  disease,  caries  of  the 
temporal  bone  and  of  the  cervical  vertebrae,  retro-pharyngeal  abscess, 
etc. ;  all  consequent  to  purulent  otitis  media.  A  case  of  this  kind 
was  reported  by  Gundrum  ^  in  1882. 

Such  dangerous  complications  result  sometimes  in  hemiplegia  and 
facial  paralysis.  Among  the  sequel*  of  scarlet  fever  should  be  men- 
tioned an  offensive  discharge  from  the  external  meatus  with  eczematous 
inflammation  and  swelling  of  the  cervical  glands,  ending  often  in 
suppuration. 

The  author  has  selected  from  his  records  103  cases  out  of  a  large 
number  seen  of  ear  disease  said  to  have  followed  an  attack  of  scarlet 
fever,  as  illustrative  in  this  connection.  Of  these,  61  were  females 
and  42  males.  The  aural  diseases  for  which  these  patients  presented 
themselves  for  treatment  were  as  follows: 

Acute  purulent  otitis  media  in       4  cases. 

Chronic  purulent  otitis  media  in  81  cases. 

Chronic  catarrhal  otitis  media  in  24  cases. 

Three  of  these  patients  were  deaf-mutes  (2  males  and  1  female),  and 
the  deafness  was  very  marked  in  9  cases. 

The  large  majority  of  these  cases  were  children,  and  in  the  cases  of 
adults  the  ear  disease  had  mostly  existed  since  childhood. 

Measles  are  of  scarcely  less  importance  as  a  factor  in  the  production 
of  aural  diseases,  the  latter  developing  in  about  the  same'manner  as 
in  scarlet  fever.  The  angina  of  both  measles  and  scarlet  fever  has  a 
special  tendency  to  extend  by  continuity  of  surface  into  the  nasal 
passages  and  into  the  Eustachian  tubes;  permanent  impairment  of 
hearing,  in  consequence  of  adhesions,  rigidity,  and  destruction  even, 
of  parts  of  the  transmitting  mechanism  is  too  often  a  result  (Spen- 

*  Ueber  den  Scharlacli  in  seinen  Beziehungen  zum  Gehoerorgan.  Volk- 
mann's  Sammlung  klin.  Vortraege,  No.  182. 

'^  A  case  of  chronic  Otorrhoea  following  Scarlatina.  Medical  News,  Aug. 
26th,  1882. 

5 


66  DIPHTHERIA. 

cer).*  In  measles,  as  in  scarlet  fever,  there  is  a  type  of  aural  compli- 
cation beside  the  one  which  corresponds  to  the  acute  catarrhal 
inflammations  which  follow  catarrh  of  the  upper  air  tract,  namely, 
that  originating  primarily  in  the  drum-head  and  accompanying  the 
appearance  of  the  cutaneous  eruption  on  the  face. 

The  author  selected  from  his  records  73  cases  of  aural  disease  said 
to  have  resulted  from  measles,  of  which  44  were  females  and  29  were 
males.     The  aural  diseases  of  these  patients  were  as  follows: 

Otitis  media  purulenta  chronica  was  present  in  47  cases. 

Otitis  media  purulenta  acuta  was  present  in       10  cases. 

Otitis  media  purulenta  subacuta  was  present  in    2  cases. 

Otitis  media  catarrhalis  chronica  was  present  in  14  cases. 

Otitis  media  catarrhalis  acuta  was  present  in        6  cases. 

Eczema  was  present  in  4  cases. 

Symptoms  of  deafness,  otalgia,  autophony  were  present  in  many  of 
these  cases. 

In  the  exanthemata,  discharge  from  the  ear  often  escapes  observa- 
tion until  the  patient  is  in  the  desquamative  stage,  and  the  more 
important  general  symptoms  have  passed.  But  aural  complications, 
which  usually  begin  along  with  the  severe  throat  manifestations  or 
when  the  mucous  surface  is  at  the  height  of  inflammation,  may  occur 
at  any  time. 

A  tabulated  report  of  the  Belgian  Government,  in  1847,  shows 
that  of  1,892  cases  of  acquired  deaf-mutism  from  all  causes, 
216  were  from  scarlatina,  80  from  measles,  and  28  from  small-pox. 
Of  86  cases  (American)  of  non-congenital  mutism,  41  were  from 
scarlatina.  Wilde,  1853,  reported  that  of  394  cases  of  acquired  deaf- 
mutism,  35  cases  followed  scarlatina,  12  small-pox,  and  7  measles 
(Spencer)." 

Diphtheria. — Diphtheritic  inflammation  of  the  middle  ear  in  scarlet 
fever  has  been  reported  by  some  authorities  as  very  common  (Wreden). 
The  diphtheritic  process  extends  via  the  Eustachian  tubes  into  the 
middle  ear,  involving  in  some  cases  even  the  labyrinth.  The  stage 
in  which  such  patients  usually  presented  themselves  for  treatment 
was  about  two  weeks  subsequent  to  the  commencement  of  the  exuda- 
tion, when  suppuration  had  been  established  (Gottstein)." 

The  author's  records  show  that  of  12  cases  of  aural  disease  claimed 

'  The  Ear  in  the  Exanthemata.  Trans,  of  the  Medical  Association  of  the 
State  of  Missouri,  1878. 

« Ibid. 

^  Beitraege  zu  den  im  Verlauf  der  acuten  Exantheme  auftretenden 
Gehoraffectionen.     Arch,  fiir  Ohrenheilkunde,  xvii.,  1,  3. 


VAKIOLA.  67 

to  have  occurred  after  diphtheria,  11  were  females  and  1  male 
Chronic  purulent  otitis  media  was  present  six  times,  and  the  acute 
form  once;  chronic  catarrhal  otitis  media  was  also  present  once,  and 
two  cases  were  suffering  from  severe  otalgia. 

Variola. — In  small-pox  the  mucous  membrane  of  the  pharynx  and 
nares  is  not  so  constantly,  but  is  commonly,  implicated,  being  affected 
by  inflammation  in  one  form  or  other  (Spencer).' 

Wendt "  dissected  the  ears  of  168  persons  who  died  from  variola 
(both  vera  and  hemorrhagica),  arriving  at  the  following  conclusions: 
That  hyperaemia  of  the  mucous  membrane  of  the  middle  ear  has  little 
or  no  influence  on  the  hearing,  etc.,  and  that,  furthermore,  variolous 
processes  proper  heal  without  injurious  effect  on  the  ear,  since  he  has 
never  found  stricture,  contraction,  or  obliteration  in  the  tube  as  the 
result  of  that  process.  Grindon '  reports  6  cases  of  otitis  media  puru- 
lenta,  occurring  as  a  complication,  out  of  310  cases  of  variola.  It 
was  present  4  times  among  134  confluent  cases,  circa  3^  per  cent. 
In  2  of  these  cases  it  followed  parotiditis.  Among  43  cases  of  dis- 
crete variola  and  36  of  the  hemorrhagic  type,  there  was  not  a  single 
case  of  this  complication;  those  of  the  last-mentioned  class  all  dying 
before  the  sequelae  appeared.  Among  107  cases  of  varioloid,  otitis 
media  purulenta  occurred  twice,  and  in  one  of  these  it  followed  an 
attack  of  facial  erysipelas.     All  6  cases  were  males. 

The  author  reports  4  cases  coming  under  his  observation.  Three 
of  these  patients  were  females.  One  patient  applied  for  treatment  for 
chronic  purulent  otitis  media  in  one  ear  and  chronic  catarrhal  otitis 
media  in  the  other,  the  deafness  being  very  great.  Two  of  the  patients 
had  ulceration  of  the  external  auditory  canal,  together  with  chronic 
purulent  otitis  media.  Chronic  catarrh  of  the  middle-ear  tract,  fol- 
lowed by  great  impairment  of  hearing,  was  the  sequel  of  variola  in  the 
only  male  patient. 

Suppurative  otitis  media  is  said  to  occur  sometimes  after  vaccina- 
tion, and  Spencer  *  and  W.  A.  Bartlett  *  have  both  reported  cases  of 
this  kind.  In  the  opinion  of  the  author,  however,  further  investigation 
will  in  most,  if  not  in  all,  cases  show  that  the  aural  disease  has  been 
falsely  attributed,  by  parents,  to  contamination  of  the  vaccine  virus. 

1  Op.  cit. 

^  Ueber  das  Verhalten  des  Gehororgans  bei  Variola.  Arch,  der  Heil- 
kunde,  1872. 

^  Otitis  Media  as  a  Sequel  of  Small-pox.  St.  Louis  Courier  of  Medicine, 
August,  1882. 

*  St.  Louis  Courier  of  Medicine,  May,  1882. 

'  New  York  Medical  Journal,  September  13th,  1884. 


68  CEKEBRO-SPmAL   MENINGITIS. 

This,  at  least,  has  been  his   experience  in  those  cases  coming  under 
his  own  observation. 

Cereh'O-spinal  meningitis  is  known  as  a  frequent  cause  of  deaf- 
ness and  deaf-mutism  in  children.  Complete  and  bilateral  loss  of 
hearing  is  the  most  usual  aural  complication  arising  from  this  disease, 
although,  according  to  J.  Lewis  Smith,'  a  mild  grade  of  otitis  media, 
subsiding  without  impairment  of  hearing,  is  common.  The  loss  of 
hearing  appears  to  take  place  in  some  cases  during  convalescence 
from  the  fever,  but  the  patients  are  mostly  observed  to  be  deaf 
when  full  consciousness  returns.  Some  authors  are  of  the  opinion 
that  deafness  following  an  attack  of  cerebro-spinal  meningitis  is  an 
exception.  It  must  be  admitted,  however,  that  numerous  cases  of 
alleged  cerebro-spinal  meningitis  in  infants  are  undoubtedly  cases  of 
acute  otitis  media.  Of  a  number  of  cases  observed  by  Smith  in  the 
epidemic  of  1872,  about  one  in  every  ten  patients  became  deaf.  Only 
one  case  of  the  ten  coming  under  his  observation  was  an  adult,  the 
others  being  all  under  ten  years  of  age.  Knapp  examined  31  cases, 
in  all  of  which  deafness  was  complete,  with  two  exceptions,  and  in 
all  bilateral.  That  many  deaf-mutes  owe  the  origin  of  their  condi- 
tion to  an  attack  of  cerebro-spinal  meningitis  in  their  infancy  has  been 
definitely  settled.  In  his  elaborate  '*  Memoir  upon  the  Formation  of 
a  Deaf  Variety  of  the  Human  Race,^'  Bell  has  shown  by  the  statisti- 
cal reports  of  two  deaf  and  dumb  asylums,  that  the  increase  in  the 
number  of  deaf-mutes  in  those  institutions  after  the  prevalence  of 
epidemics  of  cerebro-spinal  meningitis  was  very  remarkable  ;  espe- 
cially those  of  1810-1819,  and  1860-1869.  Deafness  was>bserved  by 
Upham,^  among  the  prominent  symptoms  at  one  time  or  other,  in 
twenty-one  cases  out  of  three  hundred  and  fifteen  cases  of  cerebro- 
spinal meningitis.  Concerning  the  origin  of  this  deafness;  it  may 
depend  on  an  inflammatory  lesion  at  the  acoustic  centre  in  the 
brain  or  in  the  course  of  the  nerves  of  hearing  to  the  auditory 
foramina  (according  to  Stille,  through  pressure  of  plastic  exuda- 
tion surrounding  the  nerves).  There  may  also  be  an  inflammatory 
state  of  the  labyrinth.  Heller  and  Lucae  both  found  evidences  of 
labyrinthine  disease  in  post-mortem  examinations. 

The  author,  out  a  considerable  number  of  instances,  recorded  twenty- 
six  cases  of  aural  diseases  asserted  by  the  patients  or  their  parents  to 
have  arisen  from  cerebro-spinal  meningitis.  Twelve  of  these  patients 
were  males,  fourteen  females.     Three  of  them  were  under  three  years 

'  New  York  Medical  Record,  December  8th,  1883. 

^  Boston  Med.  and  Surgical  Journal,  September  3d,  1874. 


MUMPS.      PERTUSSIS.       FEVERS.  69 

of  age,  seven  between  three  and  five  years,  eight  between  five  and  ten 
years,  five  between  ten  and  twenty  years,  one  between  twenty  and 
thirty  years,  and  two  were  over  thirty  years  of  age.  Among  these 
cases  were  seventeen  deaf-muteg,  whilst  five  were  either  totally  deaf 
or  nearly  so.  In  numerous  instances  the  results  of  arrested  develop- 
ment were  apparent  and  chronic  catarrhal  changes,  etc.  Chronic 
purulent  otitis  media  existed  in  four  cases. 

Mumps. — That  aural  disease  may  be  consequent  to  parotiditis  has 
been  occasionally  remarked.  Six  cases  with  ear  disease,  arising,  as 
far  as  could  be  ascertained,  from  an  attack  of  mumps,  presented 
themselves  for  treatment,  though  in  a  large  number  of  other  cases 
this  was  the  alleged  cause.  Four  were  females  and  two  males.  Acute 
purulent  infiammation  of  the  middle  ear  was  present  in  one  case,  the 
chronic  form  also  in  one  case.  Two  patients  had  chronic  catarrh  of 
the  middle-ear  tract,  and  two  had  acute  catarrhal  inflammation  of  the 
middle  ear.  A  few  cases  have  been  reported  where  extreme  deafness 
followed  this  disease. 

Pertussis. — Whooping-cough  is  sometimes  also  a  causative  factor  in 
the  production  of  ear  disease.  In  seven  cases  notes  were  taken  by 
the  author.  Of  these  four  were  females,  three  males.  One  of  these 
patients  had  chronic  catarrhal  and  four  had  chronic  purulent  inflam- 
mation of  the  middle  ear.  There  was  one  case  also  of  subacute 
catarrh  and  one  .of  acute  purulent  otitis  media.         ^ 

Typhoid  fever  is  very  often  alleged  to  be  the  cause  of  aural  troubles, 
by  extension  of  catarrh  of  the  air  passages  to  the  middle  ear.  This  is 
liable  to  occur  during  the  course  of  all  fevers,  the  mucous  membrane 
being  much  more  susceptible  during  the  progress  of  such  diseases. 
Among  ten  of  the  cases  of  typhoid  fever  of  which  record  was  made, 
otitis  media  purulenta  chronica  occurred  in  five  patients,  chronic  ca- 
tarrhal inflammation  in  two,  and  acute  catarrh  of  the  middle  ear  in 
one  case.  In  two  cases  it  was  doubtful  whether  the  aural  trouble  re- 
sulted from  the  typhoid  fever  or  from  other  sources  (measles,  dental 
irritation).     One  case  was  a  deaf-mute. 

Typhus,  ^^  Roman,"  ^^  malarial,"  and  other  fevers. — As  above  re- 
marked, catarrhal  inflammation  of  the  upper  air  passages  is  usually 
present  in  all  fevers,  and  aural  disease  in  consequence  is  liable  to 
occur.  The  author's  records  show  two  cases  of  typhus  fever  result- 
ing in  deaf -mutism  in  one  patient  three  years  of  age,  and  chronic  ca- 
tarrh of  the  middle  ear  in  the  other.  One  case  of  so-called  "  Eoman'' 
fever  was  followed  by  otitis  media  catarrhalis  chron.,  with  accompany- 
ing annoying  tinnitis  aurium  and  autophony.  Twenty-six  cases  of 
so-called  "malarial  fever,"  ''chills  and  fevers,''  ''intermittent  fever" 


70  CUTANEOUS   AFFECTIONS. 

were  recorded,  fifteen  of  which  were  males,  eleven  females.  The 
aural  diseases  for  which  these  patients  applied  for  treatment  were  as 
follows  : 

Otitis  media  purulenta  acuta  in  2  cases. 

Otitis  media  purulenta  chronica  in     2  cases. 

Otitis  media  catarrhalis  acuta  in  1  case. 

Otitis  media  catarrhalis  chronica  in  14  cases. 

Otitis  externa  diffusa  in  1  case. 

Otitis  externa  circumscripta  in  1  case. 

Otalgia  in  2  cases. 

In  these  cases  there  were  symptoms  of  autophony  and  general  ner- 
vous prostration,  pruritus  auris,  etc.  Syphilis  existed  in  one  case  of 
chronic  catarrh  of  the  middle  ear. 

Opinions  differ  very  much  in  regard  to  the  influence  of  a  "  mala- 
rial''  poison  in  the  production  of  aural  diseases.  Luchhau  found 
otitis  media,  both  the  catarrhal  and  the  purulent  forms,  in  fifteen 
out  of  one  hundred  and  eight  cases  of  relapsing  fever.  This  author 
does  not  think  that  the  aural  trouble  arose  from  an  extension  of  the 
catarrh  via  the  Eustachian  tubes.  Weber- Liel  describes  two  forms 
of  ear  disease  dependent  on  "malarial"  poisoning.  The  one  he 
calls  an  otitis  intermittens,  the  other  an  intermittent  otalgia,  being 
of  a  non-inflammatory  nature.  Similar  observations  have  been  re- 
ported by  Voltolini,  Oassels,  and  others.  It  seems  probable  that  the 
presence  of  catarrhal  fever  is  liable  to  be  regarded  by  many  as  "  ma- 
larial.^' 

CUTANEOUS   AFFECTIONS. 

Certain  cutaneous  diseases,  such  as  eczema,  erysipelas,  herpes,  etc.,^ 
are  more  or  less  often  causative  of  ear  affections,  through  extension 
from  the  cutaneous  surface  into  the  ear. 


CHAPTEE    YI. 

CATAERH  OF  THE  UPPEE  ATE  TEACT. 

The  origin  and  continuance  of  aural  disease  is  due  to,  or  associated 
intimately  with,  catarrhal  inflammation  of  the  upper  air-passages  in 
the  greater  number  of  instances  ;  but  acute  and  chronic  aural  catarrh, 
constituting  the  principal  affections  of  the  ear,  may  be  isolated,  or 
more  or  less  independent  of  the  former. 

It  has  not  been  long  since  inflammation  of  the  mucous  tract  of 
the  head  was  simply  known  as  a  "  gathering '^  in  the  head.  Of  late 
this  has  given  way  to  a  term  but  little  more  expressive  of  the  trouble, 
namely,  "a,  cold  in  the  head.**  Gradually,  however,  as  catarrhal  af- 
fections of  the  ear  and  nose  have  received  greater  attention,  their  im- 
portance is  more  generally  recognized,  and  it  now  seems  time  that  the 
entire  pneumatic  tract  of  the  head  should  be  considered  as  a  whole,  in 
order  that  the  etiology,  pathology,  and  treatment  of  this  region,  or 
any  of  its  parts,  may  be  intelligently  considered.  It  will  be  profita- 
ble to  those  who  have  not  already  given  the  subject  particular  atten- 
tion, to  glance  at  the  pneumatic  area  of  the  head,  as  shown  in  the  ac- 
companying diagrammatic  view  of  this  region. 

Greater  knowledge  of  the  boundaries  and  extent  of  the  tract  may, 
however,  be  obtained  by  studying  the  prepared  bones  of  the  face  and 
head.  The  osseous  fore-front  in  man  will  thus  be  seen  to  consist  of 
a  framework  not  unlike  the  bony  structure  in  birds,  where  extreme 
lightness  is  assured  without  undue  loss  of  strength — a  conformation 
well  adapted  to  the  physiological  requirements  of  the  special-sense 
nerve-distribution  to  the  ear  and  nose.  The  more  important  cavities 
of  the  head  concerned  in  catarrhal  inflammation  are  :  1,  the  tym- 
panum, mastoid  antrum,  and  cellules  ;  2,  the  turbinated  bone  inter- 
spaces, or  nasal  passages ;  3,  the  frontal  sinuses  ;  4,  the  ethmoidal 
cells  ;  5,  the  antrum  of  the  superior  maxillary  bones ;  6,  the  sphe- 
noidal sinuses.  The  large  sockets  for  the  lodgment  of  the  eyes,  the 
oro-pharynx,  and  the  pharyngeal  vault  are  also  a  part  of  this  region. 
The  various  cavities  have  connecting  sinuses,  and  the  entire  system  is 
everywhere  lined  by  mucous  membrane. 


Y2  CATARRH  OF  THE  UPPER  AIR  TRACT. 

It  is  manifest,  then,  that  no  one  part  of  the  upper  air-tract  is  lia- 
ble to  catarrhal  inflammation  altogether  independently  of  the  others. 
Before  alluding  to  causation  in  a  broader  sense,  however,  a  passing 
allusion  may  be  made  in  this  connection  to  several  important  local 
anomalies  and  affections  which  sometimes  stand  in  a  causative  rela- 
tion to  catarrh.  Thus,  deviations  of  the  nasal  septum  occur  often 
enough  to  attract  attention  to  their  possible  influence  in  causing  ca- 
tarrhal inflammation  ;  where  ,this  interferes  with  free  circulation  of 
ait  and  the  escape  of  secretions,  it  maybe  not  only  causative  of  catarrh, 
but  may  also  increase  its  dangers.  The  relations  of  deviations  of  the 
nasal  septum  to  a  high  palatal  arch  are  notably  frequent,  and  from  a 
study  of  a  large  number  of  subjects  of  this  defect  in  catarrhal  patients, 
the  author  cannot  believe  that  it  has  any  other  significance  than  that 
it  seems  to  pertain  to  individuals  with  marked  ovoidal  conformation 


Fig.  14.— Diagram  of  upper  Respiratory  Tract  and  its  Air   Chambers   (Omittino   the 

Pharyngeal  Vault). 

1, 1,  Nares;  2,  3,  4,  superior,  middle,  and  inferior  meatus;  S,  M,  L,  superior,  middle,  and  infe- 
rior turbinated  bones;  5, 5,  antrum  of  Highmore;  6,  6,  conjunctiva;  7,  7,  posterior  ethmoidal  si- 
nuses; 8,  8,  anterior  ethmoidal  sinuses;  9,  9,  sphenoidal  sinuses;  10,  10,  frontal  sinuses;  11, 11,  in- 
fundibulum;  12, 12,  Eustachian  tube;  13,  13,  tympanum;  14, 14,  mastoid  antrum;  15, 15,  mastoid 
sinuses.    Drawn  by  Dr.  Robert  Barclay  at  the  suggestion  of  the  author. 

of  the  face,  who  generally  have  high  arched  palates  along  with  the 
lengthened  facial  measurement. 

His  own  experience  in  observing  catarrhal  inflammation  of  the  head 
and  elsewhere,  leads  the  writer  to  rather  regard  it  as  the  local  mani- 
festation of  systemic  and  climatic  influences,  than,  as  some  authori- 
ties intimate,  the  result  of  a  purely  catarrhal  diathesis  to  the  local 
manifestations  of  which  treatment  is  mainly  to  be  directed.  The 
writer  can  but  think  it  a  fallacy  to  consider  even  a  strong  predisposi- 
tion, manifesting  itself  in  the  guise  of  heredity  in  persons  seldom  free 
of  catarrh,  as  demonstrating  the  purely  local  nature  of  the  trouble. 

In  defining  catarrhal  inflammatiom,  it  is  well  to  distinguish  between 


CATARRH  OF  THE  UPPER  AIR  TRACT.  73 

the  deterioration  in  mucous  surfaces  which  evinces  the  natural  retro- 
gradation  consequent  on  gradual  but  sure  decay,  and  the  conditions 
that  hasten  the  process,  and,  therefore,  call  for  medical  treatment. 
But  while  the  natural  retrogression  is  in  a  measure  irremedial,  yet  it 
is  much  less  active  in  the  strong  and  healthy.  Catarrhal  inflamma- 
tion manifests  itself  very  differently  in  different  cases  ;  thus  the 
healthy  and  strong  withstand  its  influences,  while  the  weak  and  sus- 
ceptible yield  readily.  The  predisponents  and  excitants  of  catarrh 
give  coloring  to  its  manifestations  ;  thus,  urban  and  rural  environ- 
ments, respectively,  with  the  diversity  in  the  habits  or  occupations  of 
individuals,  together  with  climatic  differences,  produce  very  different 
effects,  and  it  will  be  well  to  review  their  peculiarities  separately. 

Urlan  peculiarities. — In  cities  mental  strain  from  overwork,  worry, 
^nd  dissipations  of  every  kind — in  a  word,  civic  wear  and  tear — gives 
rise  to  nervous  exhaustion,  and  consequently  to  physical  disability. 

To  the  above  should  be  added  the  ceaseless  noise  and  the  exceed- 
ingly deleterious  dust  and  offensive  and  noxious  odors  with  which 
metropolitan  air  is  generally  laden. 

Persons  reared  in  cities  are,  moreover,  deprived  of  the  tone  and 
Tigor  imparted  by  country  life.  The  mucous  membrane  of  the  air- 
passages  in  all  persons  is  thus  exposed  to  a  variety  of  local  excitants, 
but  among  clerks  and  operatives  it  is  especially  liable  to  become  in- 
flamed. Perhaps  worse  than  all  else  is  the  pernicious  system  of  over- 
heating dwellings,  hotels,  school-houses,  public  resorts,  factories,  rail- 
way carriages,  and  sea-going  vessels.  Provision  is  thus  made  for  the 
comfort  of  the  ailing  or  indolent  on  the  one  hand,  and  the  economical 
distribution  of  heat  on  the  other,  without  due  regard  for  the  con- 
sequences on  health.  These  unwholesome  conditions  are  the  out- 
.^rowth  of  luxurious  civic  life,  the  concentration  of  mercantile  and 
manufacturing  interests,  the  criminal  neglect  to  keep  streets  and 
houses  clean,  and  defective  drainage.  Thus,  while  out-door  air  has 
its  impurities  at  all  seasons,  it  is  scarcely  possible  during  the  winter 
to  live  in-doors  without  experiencing  the  ill  effects  of  overheated  and 
impure  air,  the  tendency  of  which  is  to  deprive  persons  of  the  hardi- 
hood necessary  to  resist  the  unavoidable  and  natural  vicissitudes  of 
cut-door  life. 

The  liability  to  contract  catarrhal  affections  from  exposure  of  the 
feet,  trunk,  and  head,  in  street  cars,  to  draughts  of  cold  air  in  all 
seasons  is  very  great. 

Rural  peculiarities. — Very  different  from  the  foregoing  are  the 
usual  conditions  of  country  life;  here  physical  overwork  is  more 
likely  to  be  met  with  as  compared  with  mental,  although  worry  and 


T4r  CATARRH     OF    THE    TIPPER    AIR    TRACT. 

grief  in  various  forms  are  not  unknown.  Among  pioneers  in  new 
settlements  homesickness  often  exists,  the  food  supply  frequently  is 
inadequate,  and  habitations  damp,  cold,  and  dark.  The  statement 
applies  to  laborers  in  public  works,  and  often  to  men  in  the  frontier 
military  service.  In  older  and  improved  country  places,  where 
extreme  exposure  is  exceptional,  catarrhal  inflammation  is  not  so 
severe,  yet  the  causal  influences  and  symptoms  differ  from  those  of 
the  city.  It  may  be  said  that  the  rural  subject  presents  the  sthenic 
type,  with  greater  temperature  disturbance,  while  in  the  city  patient, 
if  a  subject  of  nervous  exhaustion,  it  is  more  likely  to  assume  an 
asthenic  form. 

The  difference  in  the  phenomena  observed  in  what  may,  for  com- 
parison, be  designated  as  two  classes  of  catarrhal  disease  serves,  per- 
haps, to  explain  some  apparent  discrepancies  in  the  conclusions  arrived 
at  by  medical  men,  who  have  looked  on  the  same  disease  from  a  differ- 
ent point  of  view,  some  regarding  it  as  catarrhal  inflammation,  others 
as  malarial  fever. 

But  this  is  not  so  surprising,  since  catarrhal  inflammation  often 
exhibits  symptoms  commonly,  though  wrongly,  ascribed  to  malaria; 
thus  fever  is  often  present,  being  ushered  in  with  chills;  there  is  a 
tendency  to  recurrence,  malaise,  depression  of  spirits,  vertiginous 
symptoms,  and  the  like.  The  subsequent  debility  and  typhoidal 
symptoms,  wh^n  present,  are  therefore  liable  to  mislead  the  observer,, 
especially  if  he  be  a  believer  in  the  production  of  typhoid  fever  from 
"malarial"  influences.  One  should  reflect  here  on  the  possibility  of 
these  symptoms  being  due  to  disturbance  of  the  nervous  system 
wholly. 

Malaria  has  long  been  a  convenient  cloak  for  our  ignorance  in 
respect  to  the  origin  of  disease.  The  writer  recollects  how  the 
''bilious  remittent"  fever  of  the  Southwest  was  attributed  to  this 
cause  in  his  early  experience;  and  an  outbreak  of  so-called  "  typho- 
malarial "  fever  among  the  soldiers  of  his  regiment  while  stationed  in 
the  Alleghanies,  in  1861,  occurring  after  some  weeks'  exposure  in 
camp,  especially  to  night  air,  was  alleged  to  be  due  to  this  agency^ 
The  popular  mind  to-day  gives  credence  to  this  mysterious  influence, 
as  it  always  has  done  for  hundreds  of  years. 

Says  Cooke,  in  a  recent  work  on  Virginia,  speaking  of  the  early 
settlers  on  the  James  River  in  1607  :  "  With  July  came  the  sultry 
dog-days  of  a  southern  summer,  and  the  marshy  banks  of  the  river, 
sweltering  in  the  sun,  sweated  a  poisonous  malaria  which  entered  into 
the  blood  of  the  English.  The  whole  colony  was  prostrated  by  a 
virulent  epidemic."    Thus,  as  at  tide-water  two  hundred  and  fifty- 


CATARRH    OF    THE    UPPER    AIR    TRACT.  75 

four  years  before,  was  the  origin  of  a  disease  assigned  to  the  same 
causation  in  the  mountains  in  1861.  In  both  of  the  instances  named, 
men  were  suddenly  transferred  from  civil  life  to  an  out-door  exis- 
tence, in  which  little  care  was  taken  to  properly  habituate  themselves; 
sometimes  they  were  idle  and  inactive  for  weeks  and  months,  until  some 
emergency  called  forth  their  utmost  exertions,  leaving  many  greatly 
exhausted.  As  a  class  they  were  without  self-restraint,  and  neglect- 
ful in  respect  to  both  food  and  hygiene.  Were  not  physical  influences 
manifestly  the  cause  of  whatever  affection  these  people  had,  rather 
than  mythical  ones  ?  A  gentleman,  competent  to  give  an  intelligent 
opinion,  and  who  has  long  practised  medicine  in  tropical  South 
America,  once  said  to  the  writer,  in  discussing  this  subject,  that  it 
was  his  belief  that  the  severe  fevers  of  that  country  might  justly  be 
regarded  as  an  aggravated  form  of  catarrhal  inflammation. 

The  confounding  of  symptoms  alleged  to  arise  from  so-called  ma- 
larial poisoning  with  catarrhal  inflammation  (inclusive  of  nervous 
phenomena  so  often  present)  seems  to  have  for  its  origin  the  belief 
that  a  malignant  miasm  exists  in  the  emanations  arising  from  decay- 
ing animal  or  vegetable  matter,  sewer-gas,  stagnant  water,  etc.,  or  is 
disseminated  by  the  pollen  or  effluvium  of  plants.  It  is  to  be  re- 
gretted that  the  accumulated  literature  of  this  subject,  embracing 
the  labors  of  writers  for  many  centuries,  cannot  by  incontestable  evi- 
dence establish  these  tenets  ;  proof  of  the  existence  of  malarial  poison, 
according  to  a  contemporary  authority,  lies  mainly  in  the  alleged 
fact  that  the  sickness  it  causes  yields  to  the  administration  of 
quinine. 

In  accepting  the  miasmatic  origin  of  disease,  it  has  been  found 
convenient  to  explain  its  morbific  influence  through  zymotic  action, 
and  more  recently  the  microbic  theory  has  been  advanced ;  but 
whether  the  "  fermentation  "  of  zymosis  and  the  presence  of  bacteria 
in  the  blood  are  not  a  product  rather  than  a  cause  of  disease,  may 
well  be  believed. 

The  neglect  of  cleanliness,  or,  more  broadly,  of  sanitation,  is 
fraught  with  much  evil ;  but  while  fully  recognizing  the  danger  to 
health  from  decomposition  of  animal  and  vegetable  matter,  would 
not  a  healthier  sanitation  prevail  were  the  popular  "  fetich  of  the 
sewer,"  to  which  such  quantities  of  quinine  are  sacriflced,  put  aside  ? 
How  often  has  house-drainage  been  laid  under  unjust  suspicion  in 
pursuit  of  this  imaginary  evil ;  the  wall-paper  of  the  sick-room  even 
torn  down  in  the  search  after  the  sewer-pipe  has  been  overhauled,  or 
the  house  abandoned  entirely  ?  How  often  have  worry,  dissipation, 
and  exposure,  lowering  the  tone  of  the  nervous  system,  overtaxing 


76  CA.TARRH    OF    THE    UPPER   AIR    TRACT. 

the  stomach  with  alcoholic  drinks  and  indigestible  food  taken  at  all 
hours,  breathing  the  poisonous  air  of  the  ball-room,  theatre,  and  the 
like — probably  continued  for  a  "  season  " — been  the  cause  of  sickness 
unjustly  attributed  to  defective  drainage  ? 

It  may  be  well  to  consider  the  causes  of  catarrh  of  the  head  some- 
what broadly,  since  the  belief  has  taken  deep  hold  on  the  minds  of 
many  that  the  malady  is  purely  local ;  when  the  influences  lying  be- 
hind local  manifestations  are  thus  recognized,  it  is  believed  a  more 
rational  treatment  will  prevail.     Among  the  causes  are  : 

Meteorological  influences. — Lightning  stroke,  sunstroke,  and  con- 
gelation are  not,  of  course,  in  the  ordinary  sense,  to  be  considered  as 
causal ;  it  is  the  less  or  entirely  inappreciable,  and  hence  unexpected, 
variations  in  meteorological  conditions  that  interest  us,  more  espe- 
cially because  they  are  liable  to  be  underestimated  or  overlooked  en- 
tirely. These  changes  consist  in  variations  in  thermal,  electrical,  and 
aqueous  vapor  tension,  inclusive,  consequently,  of  the  relative  amount 
of  sunlight,  oxygen,  ozone,  etc.  The  most  .important  of  these,  and 
doubtless  influencing  them  all  in  greater  or  less  degree,  is  the  heat 
radiated  from  the  sun.  Animal  and  vegetable  life  upon  the  earth's 
crust  derive  their  vitality  from  this  source.  It  is  the  struggle  against 
the  undue  loss  of  this  heat  through  radiation  from  the  earth's  surface 
on  the  one  hand,  and  the  avoidance  of  an  excessive  supply  on  the 
other  hand,  in  order  that  a  healthful  equilibrium  may  be  maintained, 
that  concerns  the  sanitarian.  Circumstances  Have  placed  man  alike 
in  warm  and  cold  climates,  as  well  as  in  the  more  favored  temperate 
latitudes ;  the  latter  is  most  favorable,  since  out-door  life  may  be  en- 
joyed to  a  greater  extent  than  elsewhere.  It  behooves  one,  therefore, 
in  considering  the  causes  of  catarrhal  inflammation,  to  take  into 
€0unt  weather  vicissitudes,  including  a  study  of  meteorological  phy- 
sics, the  laws  regulating  heat,  electrical  and  aqueous  vapor  tension, 
the  movements  of  wind  and  water  (trade  and  anti-trade  winds  and 
ocean  currents) ;  the  proportion  of  oxygen,  ozone,  etc.,  under  varying 
conditions. 

The  functions  of  life  for  the  most  part  must  be  carried  on  in  an  en- 
vironment of  ever-changing  physical  forces.  "We  may  be  said  to  live 
amidst  ceaseless  aerial  cyclonic  movements  of  greater  or  less  energy, 
since  the  air  is  ever  in  motion  ;  these  storms — sometimes  one  follow- 
ing the  other,  sometimes  moving  along  in  an  irregular  manner 
together — traverse  to  a  greater  or  less  extent  the  entire  continent, 
disturbing  a  varying  area  of  territory.  As  the  cyclone  constituting 
the  ordinary  thunder-storm  advances,  there  is  always  a  higher  tem- 
perature in  front  than  in  the  rear — *'the  warm  air  in  front,"  accord- 


CATARRH  OF  THE  UPPER  AIR  TRACT.  TT 

ing  to  Mr.  Abercromby/  ''having  a  peculiar,  close,  muggy  character. 
The  cold  air  iu  the  rear,  on  the  contrary,  has  a  peculiarly  exhilarat- 
ing feeling."  These  conditions  are  quite  independent  of  the  thermo- 
metrieal  condition. 

The  following  puzzling  experience  is  illustrative  of  the  effect  of 
these  influences  ;  it  occurred  in  the  writer's  early  experience  in  prac- 
tice. The  patient  was  a  man,  aged  forty -five,  whose  general  health 
was  fair ;  on  entering  the  sick-room  the  writer  found  him  gasping  for 
breath.  The  heart  was  beating  tumultuously,  and  his  nervousness  was 
painful  to  witness.  He  had  been  attacked  with  these  symptoms  on 
the  approach  of  a  thunder-storm  which  was  then  prevailing.  His 
wife,  who  showed  no  alarm,  informed  the  author  that  he  always  suf- 
fered in  this  manner  during  storms,  and  that  recovery  was  always 
speedy  and  complete  as  soon  as  the  weather  cleared. 

Sudden  and  extreme  changes  in  altitude  also  give  rise  to  peculiar 
disturbances;  persons  on  arriving,  by  rail,  at  an  elevation  of  some  six- 
teen thousand  feet  in  the  Andes,  are  liable  to  experience  very  dis- 
agreeable sensations,  due  to  the  sudden  withdrawal  of  atmospheric 
tension.  Besides  the  cardiac  failure  and  pulmonary  derangement 
produced  by  the  transition,  congestion  and  anaesthesia  of  the  skin, 
cramps,  and  other  nervous  disturbances  are  experienced,  known  in 
South  America  as  "aire."  ^  Similar  to  phenomena  occurring  in  very 
much  rarefied  air  are  those  witnessed  in  persons  exposed  to  the  highly 
condensed  air  of  submarine  caissons  ;  in  either  the  sudden  disturbance 
of  equilibrium  of  density  causes  undue  nervous  strain. 

It  is,  however,  the  much  more  slight  variations  associated  with 
storm  movements  that  probably  give  rise  to  the  nervousness  ex- 
perienced by  certain  individuals.  The  writer  has  been  informed  by 
a  number  of  his  patients  that  they  cannot  long  endure  a  sea-side 
residence  in  summer,  even  in  so  agreeable  a  place  as  Newport,  R.  I., 
on  account  of  the  extreme  nervousness  apparently  produced  by  an 
environment  affected  by  wind  that  has  swept  rapidly  over  the  ocean 
for  a  long  distance.  Besides  the  general  nervousness  experienced, 
there  was  irresistible  somnolency  at  one  time,  and  at  another  a  total 
inability  to  obtain  sleep. 

The  writer  believes  that  natural  electrical  disturbances  exert  an 
important  influence  on  the  health  of  persons  whose  nervous  systems 
have  been  impaired  by  exhaustion,  causing  undue  excitation  or  de- 

1  Nature,  1885, 

*  Report  of  Medical  Inspector  Benjamin  F.  Gibbs,  U.  S.  Flag-ship  Rich- 
mond, South  Pacific  Station,  1876. — Hygienic  and  Medical  Reports  by  Medical 
Officers  of  the  U.  S.  Navy.    Washington,  1879.    Page  270. 


78  CATARRH  OF  THE  UPPER  AIR  TRACT. 

pression  according  to  the  positive  or  negative  state  affecting  them. 
Indeed,  it  is  probable  that  very  slight  disturbances  of  electrical 
tension  often  produce  decided  nervous  phenomena.  These  electrical 
variations  have  not,  as  yet,  been  fully  studied,  but  many  observations 
have  been  made  going  to  prove  their  existence.  Thus,  the  author 
has  been  informed  by  Dr.  James  P.  Kimball,  now  Director  of  the 
Mint,  that,  what  he  has  long  suspected  as  causing  this,  namely,  dis- 
turbance of  electrical  equilibrium  by  the  wind  in  motion,  is  true  ; 
that  during  certain  high  winds  the  electrometer  showed  a  decided 
variation.  Observations  in  respect  to  the  electrification  of  the  air 
have  also  been  made  elsewhere  ;  in  referring  to  the  "  normal  positive 
difference  of  potential  between  a  point  some  few  feet  above  the  earth 
and  the  ground  itself,"  C.  Michie  Smith,'  of  the  Madras  Christian 
College,  points  out  "  that,  in  Madras,  at  least,  a  negative  electrifica- 
tion of  the  air  was  a  normal,  and  not  an  abnormal  condition  for  many 
hours  of  the  day  at  certain  seasons  of  the  year.  Observations  since 
taken  have  entirely  confirmed  the  opinion  that  with  a  hot,  dry,  west 
wind  the  air  in  Madras  is  usually  negatively  electrified,  and  often  to 
a  very  high  potential."  .  .  .  ''During  periods  of  incessant  dis- 
charges of  sheet  lightning  which  we  often  experience  here,  the  elec- 
trification of  the  air  is  sometimes  positive  and  at  other  times  nega- 
tive, but  generally  positive." 

Thermal  changes  are  yet  more  important  than  either  electrical  or 
barometrical.  The  rapid  liberation  of  heat  from  the  body  of  the 
strong  generally  arouses  healthful  activity,  but  it  depresses  the 
weak ;  on  the  other  hand,  the  acquisition  of  a  relatively  great 
amount  of  heat  is  well  borne  by  the  former,  while  prostrating  the 
latter. 

Prolonged  exertion  in  extreme  summer  heat  gives  rise  to  nervous 
prostration  or  irritability  ;  this  is  especially  liable  to  occur  during  the 
*' dog-days"  of  summer,  the  mean  daily  temperature  continuing 
high,  when  even  slight  exercise  is  fatiguing  and  attended  with 
perspiration.  A  draught  of  air  is  then,  according  to  the  Spaniards, 
una  facada,  a  knife-stab,  so  dangerous  is  it  regarded.  But,  as  would 
be  expected,  exposure  to  night  air  when  the  sun's  heat  is  withdrawn, 
is  particularly  dangerous  to  the  susceptible. 

(As  we  approach  tropical  climates,  the  transition  from  night  to  day 
and  from  day  to  night  is  sudden,  and  without  the  twilight  of  more 
northern  latitudes.) 

It  is  then  that  sudden  cooling  off,  especially  in  damp  clothing, 

'  Nature,  January  39th,  1888. 


CATAKRH    OF   THE    UPPER   AIR   TRACT.  79 

and  while  the  body  is  overheated,  that  catarrhal  inflammation  may 
occur. 

It  was  long  ago  shown  by  Dr.  Wells  that  when  the  sun  has  set  the 
earth's  surface  becomes  quickly  cooled  by  radiation,  and  the  air  im- 
mediately above  becoming  too  cold  to  retain  its  aqueous  vapor  in  a 
state  of  suspension,  the  moisture  is  therefore  rapidly  deposited  upon 
the  earth  in  the  form  of  dew  or  frost,  according  to  the  lowness  of 
temperature.  It  will  be  observed  that  dampness  often  shows  itself 
upon  the  turf  sometimes  before  the  sun  has  sunk,  and  from  this  on 
the  dampness  and  chilliness  of  the  under  stratum  of  air  increases 
more  and  more  up  to  a  certain  point.  The  intelligent  class  of  natives 
of  the  tropics  practise  much  caution  to  avoid  the  deleterious  effects 
of  this  exposure,  but  notwithstanding  their  prudence,  catarrhal 
affections  of  a  severe  character  prevail.  This  result  is  less  surprising, 
however,  when  the  effect  of  prolonged  summer  heat  in  producing 
apathy  and  inertia — totally  preventing  exercise,  and  thus  increasing 
susceptibility — is  considered. 

Night  air  at  sea  is  likewise  to  be  avoided,  since  even  the  general 
bracing  effect  of  ocean  air  by  no  means  insures  immunity  from 
catarrhal  trouble. 

Usually,  however,  we  have  to  consider  the  influence  of  slight  im- 
pressions only  on  the  nervous  system  ;  these  have  been  distinguished 
as  a  "shock"  or  a  "stab,''  although  but  a  slight  immediate  effect 
is  experienced.  In  the  end,  however,  very  decided  phenomena  are  pro- 
duced through  the  vaso-motor  system  of  nerves.  A  susceptible 
person  may  not  remain  with  uncovered  head  for  many  minutes  in  the 
dew-laden  tropical  night  air  without  sneezing  or  even  contracting 
rhinitis.  Greater  or  long-continued  exposure,  especially  in  run-down 
persons,  may  be  followed  by  ague,  dengue,  neuralgia,  or  rheumatism, 
according  to  the  patient's  idiosyncrasy  or  susceptibility.  Of  course, 
the  hardy  native  "  of  the  soil,"  so  to  speak,  becomes  acclimated  to 
vicissitudes  by  long  residence,  and  even  the  languid  and  more  un- 
strung resident  acquires  immunity  not  to  be  enjoyed  by  strangers. 

Thermal  variations,  otherwise  inappreciable,  visibly  affect  the  sys- 
tem when  run  down  ;  thus,  in  a  six-days'  summer  voyage  from  Suez 
to  Aden,  says  Medical  Director  Delavan  Bloodgood,  U.  S,  N".,  in  a 
letter  to  the  writer,  the  temperature  was  seldom  lower  than  100°  Fah- 
renheit, day  or  night ;  on  entering  the  Gulf  of  Aden,  however,  a 
breeze  encountered,  only  a  few  degrees  lower,  produced  such  a  chilling 
sensation  that  the  passengers  found  an  increase  of  clothing  absolutely 
necessary.  This  gentleman  recalls  now,  after  many  years,  the  chat- 
tering of  his  teeth  on  that  occasion,  and  the  discomfort  lasted  for 


80  CATAKRH  OF  THE  UPPER  AIR  TRACT. 

several  hours.  It  is  not  unusual  under  these  circumstances  to  experi- 
ence an  immense  increase  in  urinary  secretion,  and  the  ship's  surgeon 
in  consequence  always  receives  the  visits  of  a  large  number  of 
surprised,  if  not  alarmed,  passengers.  Experiences  of  practical 
interest  bearing  on  this  point  are  common  enough  to  travellers.  Thus 
Stanley  found,  after  travelling  for  some  considerable  time  in  the 
relaxing  climate  of  equatorial  Africa,  that  warm  clothing,  including 
an  ulster,  was  comfortable  in  July,  when  the  minimum  temperature 
was  63°  P. ;  and  the  draughts  of  wind  sweeping  down  the  gorges, 
though  not  decreasing  temperature  thermometrically,  added  greatly 
to  the  feeling  of  "miserable  chilliness."  The  catarrhal  manifesta- 
tions which  seemed  to  prevail  on  the  Congo  under  those  circumstances 
were  of  the  gastric  variety.  Mr.  Crawford,  a  gentleman  engaged  in 
selecting  a  railway  route  across  the  Pampas  during  the  hot  months,- 
notes  the  rapid  changes  in  temperature  on  La  Plata ;  a  sudden  fall 
from  great  heat  to  26°  F.,  water  freezing  in  the  tents  on  one  occasion^ 
and  at  Mercedes  on  another,  after  an  intensely  cold  night,  the 
thermometer  registering  34°  F.,  the  temperature  rose  to  107°  F.  in 
the  shade  at  4.30  p.m. 

Forbes,  while  travelling  in  the  Eastern  Archipelago,  found  the 
natives  in  Sumatra  going  about,  and  even  sleeping,  in  all  weathers, 
nearly  naked,  and  enjoying  good  health  ;  but  almost  at  once  succumb- 
ing to  the  low  temperature  of  mountain  heights,  often  actually  dying 
before  they  could  descend.  Mr.  Forbes,  in  his  admirable  work  ''The 
Wanderings  of  a  Naturalist  in  the  Eastern  Archipelago, ''  states  that, 
at  an  elevation  of  10,562  feet  up  the  Dempo,  the  midday  sun  was 
almost  unendurably  hot,  the  hands,  face,  and  neck  being  scorched 
the  moment  they  came  into  the  sunshine,  though  a  cold  wind  was 
blowing  and  the  thermometer  registered  only  63°  F.  "When  the  sun 
began  to  deline,  however,  the  temperature  fell  rapidly  ;  at  sunset  it 
was  47.2°  F.,  and  for  comfort  he  was  obliged  to  put  on  three  suits  of 
clothes. 

'*  When  at  four  o'clock  next  morning,"  says  Mr.  Forbes,  "  I  went 
out  into  the  Sawah,  though  the  thermometer  registered  47°  F.  (the 
lowest  reading  of  the  night  was  42°  F.),  the  air,  which  was  perfectly 
still — its  silence,  indeed,  almost  overwhelming — felt  absolutely  free 
from  rawness,  in  marked  contrast  to  what  I  had  experienced  at  sunset 
under  almost  the  same  reading  of  the  thermometer." 

Mental  exhaustion  alone,  without  open-air  exposure,  is  very  often 
a  cause  of  head  catarrh;  yet  may  one  sleep  in  a  cold,  airy  apartment, 
when  not  overheated,  without  risk,  and  patients  with  high  tempera- 
ture, unless  sweating  excessively,  get  on  best  with  such  surroundings. 


CATARRH    OF   THE    UPPEE   AIR   TRACT.  81 

Causative  influences  like  the  foregoing  finally  prevent  healthful 
equipose  between  the  different  organs,  and,  in  consequence  of  this, 
elimination  is  defective.  Along  with  defective  nutrition  a  perverted 
state  of  the  nervous  system  obtains;  its  tension,  on  the  one  hand,  is 
depressed,  or,  on  the  other  hand,  increased.  At  either  extreme,  or 
in  vibrating  between  them,  peculiar  phenomena  present  themselves; 
thus  periodical  disturbances  influencing  temperature  may  characterize 
catarrhal  fever,  or  they  may  manifest  themselves  as  '•  nervous  explo- 
sions "  at  irregular  intervals.  Certain  subjects  become  known  as 
"  nervous,"  and  are  liable  to  uncontrollable  sighing,  weeping,  out- 
bursts of  ill-temper,  and  other  emotional  manifestations.  Others 
thus  illy-balanced  indulge  inordinately  in  stimulants,  or  food,  or 
sexual  excess.  It  is  a  notable  fact  that  such  nervous  persons  are  ex- 
tremely subject  to  catarrhal  inflammation,  which  is  liable  to  take  on 
nervous  characteristics.  Thus,  with  bronchitis  appears  the  suffo- 
cating spasm  of  asthma,  and  with  rhinitis  tlie  violent  irritation  and 
sneezing  of  hay-fever.  Catarrhal  neuroses,  once  acquired  by  the 
more  susceptible,  increase  by  long  continuance  to  a  degree  never  ex- 
perienced by  less  sensitive  persons.  These  local  disturbances  of  the 
mucous  surface  are  comparable  to  neuroses  of  the  skin,  as  zoster  and 
pruritus,  where  cutaneous  burning  and  itching  are  caused  by  reflex 
action.  . 

Where  the  asthmatic  habit  exists,  meteorological  disturbances,  ex- 
cessive physical  exertion,  undue  mental  excitement  or  depression, 
cold  winds  and  dust,  excite  spasm  and  cough.  The  sight  of  dust, 
even  without  inhaling  it,  will  excite  spasmodic  cough;  indeed,  almost 
every  asthmatic  has  his  hete  noire,  which  may  explain  the  whimsical 
origin  of  asthmatic  spasm  in  some  cases. 

In  the  disordered  olfaction  of  hay  or  rose  fever,  the  odor  of  the 
rose  and  other  objects  is  compared  to  the  irritation  of  pepper  applied 
to  the  Schneiderian  membrane,  and,  as  in  asthma,  various  dusts  and 
odors  cause  distress. 

The  rhinitis  of  hay  and  rose  fever  is  often  found  to  stand  in  a 
causal  relation  to  otitis,  affecting  the  ears  either  by  extension  of  the 
inflammatory  process  from  the  naso-pharynx  up  along  the  Eustachian 
tube  to  the  tympanum,  or  through  reflex  sympathy  of  the  nerves. 

The  more  decided  catarrhal  attacks  are,  of  course,  well  known  to  be 
ushered  in  by  a  chill,  with  more  or  less  nervous  disturbance ;  some- 
times a  local  manifestation  also  occurs,  as  torticollis,  or  a  ''crick" 
in  some  other  region.  In  the  greater  number  of  cases,  however,  in- 
tense congestion  of  the  Schneiderian  membrane  occurs,  producing 
6 


82  CATARRH  OF  THE  UPPER  AIR  TRACT. 

sensations  of  dryness  and  heat,  violent  and  persistent  sneezings,  and 
often  a  tickling  feeling. 

Secretion  in  catarrhal  inflammation  is  generally  characteristic  ; 
thus  the  outpour  of  fluid  from  the  inflamed  mucous  membrane  of  the 
nose  in  children,  after  the  feverish  stage  at  the  onset,  is  profuse,  as  it 
also  is  in  recurrent  rhinitis  in  adults,  notably  in  hay-fever.  Incrus- 
tations of  inspissated  muco-pus  in  the  caverns  of  the  nose,  especially 
where  a  deviation  of  the  septum  exists,  are  seldom  seen  before  puberty; 
but  in  chronic  catarrh  in  cachectic  persons,  or  in  advanced  life, 
where  the  mucous  membrane  enveloping  the  erectile  tissue  of  the 
nose  has  become  atrophied,  evaporation  of  the  scanty  secretion  leaves 
inspissated  crusts,  which  often  soon  become  fetid. 

Bleeding  abrasions,  due  to  congestion  of  the  nasal  mucous  mem- 
brane, especially  in  persons  living  under  mental*  strain  and  worry,  are 
common  and  liable  to  become  the  seat  of  these  crusts.  The  latter 
cause  much  discomfort,  their  removal  being  often  followed  by  more 
or  less  bleeding.  In  some  cases  the  perichondrium  is  exposed  and  the 
septum  may  even  finally  become  perforated.  Tliere  is  an  interme- 
diate- stage  when  mucous  secretions  become  very  tough  on  drying 
and  are  worked  out  with  difficulty.  Secretion  may  consist  of  mucus 
principally,  or  it  may  become  sero-mucous,  sero-sanguinolent,  muco- 
purulent, purulent,  or  otherwise  combined,  according  to  circumstances. 
During  the  further  progress  of  the  trouble  the  lower  air-tract  is  often 
invaded,  accompanied  by  cough  and  other  symptoms  of  bronchial 
catarrh. 

Head  catarrh  often  begins  very  early  in  life,  and  continues  a  long 
time  before  the  subject  is  brought  to  the  physician's  notice.  In  fact, 
it  is  usually  neglected  until  marked  deafness  has  occurred.  The  neg- 
lect of  nasal  catarrh  is  often  due  to  the  indifference  to  the  slight  dis- 
comfort attending  impairment  of  smell,  since  at  best  this  function  is 
less  perfect  from  disuse  or  want  of  cultivation  than  that  of  the  other 
special  senses.  In  a  few  instances  the  author  found  the  sense  of 
smell  most  acute,  resembling  that  of  many  of jthe  lower  animals,  where 
its  importance  in  the  economy  is  scarcely  second  to  hearing  and 
seeing. 

Sympathy  of  the  Nerves. — In  certain  conditions  of  the  system  the 
nerves  become  exceedingly  impressible  to  excitation;  thus  the  irrita- 
tion produced  by  the  introduction  of  a  speculum  or  a  probe  into  the 
external  auditory  canal  will  excite  coughing,  or  a  desire  to  swallow, 
and  various  other  sensations  in  the  nose,  pharynx,  or  larynx.  Many 
persons  can  locate  the  seat  of  local  irritation  thus  propagated  in  the 
ear  in  some  particular  spot  in  these  parts,  the  sensation  being  de- 


CATARRH  OF  THE  UPPER  AIR  TRACT. 


83 


scribed  as  "  burning,"  "  tickling,"  and  the  like.  TJiere  is  very  often 
cm  increase  in  the  secretion  of  mucus  in  the  spot  thus  irritated. 
When  the  throat  is  in  a  diseased  condition,  the  reverse  of  the  above 
often  takes  place,  and  the  ear  may  then  become  affected.  When 
nerve-tension  has  been  long  disturbed  in  this  way,  reflex  phenomena 
are  easily  excited;  continuous  aural,  nasal,  or  dental  irritation,  even 
if  imperceptible,  may  affect  one  part  or  another,  until  nutritive 
(trophic)  changes  are  brought  about;  slowly  progressive  aural  catarrh 
finally  producing  deafness  before  the  patient  himself  is  aware  of  any 
morbid  action  going  on.  The  tissues'involved  in  catarrhal  inflamma- 
tion of  the  .middle  ear  consist  of  a  membrane  which  performs  the 
double  duty  of  mucous  membrane  and  periosteum.     The  sensitive- 


FiG.  15.— Diagram  op  the  Tympanic  Plexus  (Rudinger). 

1,  Oeulo-motor  nerve;  2,  trigeminus  nerve,  with  the  Gasserian  ganglion;  3,  first  branch  of  the 
trigeminus  nerve;  4,  second  branch;  5,  entrance  of  the  same  into  the  spheno-palatine  fossa;  6 
and?,  superior  maxillary  nerve;  8,  spheno-ethmoidal  nerve;  9,  descending  palatine  nerve;  10, 
Vidian  nerve;  11,  large  superior  petrosal  nerve;  12,  buccinator  nerve;  13  and  14,  pterygoid 
nerve;  15,  chorda  tympani  nerve;  16,  carotid  plexus  of  the  sympathetic;  17,  petrosal  ganglion 
of  the  glosso-pharyngeal  nerve;  18,  19,  and  21,  vagus,  accessory  nerve  of  Willis,  and  hypoglos- 
sus;  20,  facial  nerve ;  22,  nerval!  carotico-tympanici ;  23,  tympanic,  or  Jacobson's  nerve;  34, 
small  superficial  petrosal  nerve;  25,  nerve  of  the  tensor  tympani;  26,  tympanic  plexus;  27, 
branch  for  the  oval  vrindow;  28,  branch  for  the  roimd  window;  29,  large,  deep-seated  petrosal 
nerve;  30,  branch  for  the  Eustachian  tube;  31,  division  of  the  Vidian  nerve  into  its  two 
branches;  32,  anastomosis  of  fasciculus  of  the  Vidian  nerve. 


ness  of  this  structure  is  extremely  great,  for  it  is  not  only  richly  sup- 
plied with  blood-vessels,  but  also  wonderfully  well  provided  with 
sensory  nerves.  These  latter  compose  the  tympanic  plexus,  a  dia- 
gram of  which  is  here  shown.  This  anastomosis  derives  supplies 
from  sources  most  extensive;  thus  by  means  of  branches  from  the 
otic  ganglion  the  inferior  maxillary  nerve  is  brought  into  intimate 
relations  with  it,  and^the  petrosal  ^ganglion  of  the  glosso-pharyngeal 


84:  CATARKH  OF  THE  UPPER  AIR  TRACT. 

nerve  supplies  the  tympanic  branch,  or  Jacobson's  nerve,  which  con- 
stitutes a  large  portion  of  this  anastomosis.  The  carotid  plexus  of 
the  sympathetic  sends  a  branch  to  the  glosso-pharyngeal,  and  thus 
establishes  a  communication  between  the  ear  and  the  superior  cervical 
ganglion  of  the  sympathetic  nerve.  Through  Meckel's  ganglion,  by 
means  of  the  Vidian  nerve,  the  superior  maxillary  of  the  fifth  pair  of 
nerves  also  is  connected  with  the  tympanic  system.  Besides  these, 
there  are  other  connections  which  may  be  seen  by  consulting  the 
diagram. 

This  extensive  nervous  connection  brings  the  ear  into  sympathetic 
relationship  with  disturbances  in  various  parts,  as  the  brain,  stomach, 
heart,  genito-urinary  organs,  and  cutaneous  surface,  as  well  as  with 
other  parts  already  mentioned. 

From  an  etiological  point  of  view,  catarrhal  affections  of  the  upper 
air-tract  should  be  considered  as  a  whole,  although  the  ear,  as  before 
stated,  as  well  as  the  olfactory  region,  or  in  fact  any  of  the  other 
cavities  and  sinuses  of  the  head  may  become  independently  affected. 
The  special  catarrhal  affections  of  the  ear  will  be  considered  in  another 
part  of  this  work.  Of  great  importance,  and  one  too  often  overlooked 
entirely,  is  the  influence  of  dentition,  together  with  the  retention  of 
dead  teeth,  etc.,  in  the  jaws,  as  active  causative  agents  of  catarrh. 

Invasion  of  the  upper  air-tract  by  catarrhal  inflammation  is,  as  al- 
ready stated,  common  in  a  large  majority  of  aural  diseases.  Among 
the  recorded  cases  of  the  author's,  catarrh  of  these  parts  has  been 
noted  down  as  being  very  marked  in  1,772  cases  of  aural  trouble. 
An  analytical  tabulation  of  these  shows  the  relative  age,  sex,  and 
other  conditions  with  which  aural  disease  is  generally  found  to  exist. 

FEMALES.  MALES." 

Age.                             No.  of  cases.             Age.  No.  of  cases. 

Under  3  years,'    ....  25  Under  3  years,  .        .        .        .37 

8  to  6  years,      .        .        .        .  69  3  to  6  years,  ....        53 

6  to  15  years 173  6  to  15  years,  ...           163 

15  to  20  years,           .        .        ,  68  15  to  20  years,  ....       105 

20  to  30  years,      .        .        .        .  156  20  to  30  years,  .        .        .        .244 

30  to  40  years,  ....  98  30  to  50  years,  ....      350 

40  to  50  years,      ....  75 

Over  50  years,  ....  49  Over  50  years 108 

713  1,059 

Total  Males, 1,059 

Total  Females 713 


Grand  Total 1,772 


CATARRH  OF  THE  UPPER  AIR  TRACT,  85 

The  ear  diseases  with  which  these  patients  were  affected  were  as 
follows  : 

Otitis  Media  Catarrhalis  Chronica, 863 

Otitis  Media  Catarrhalis  Acuta, 138 

Otitis  Media  Catarrhalis  Subacuta, 85 

Otitis  Media  Purulenta  Chronica, 398 

Otitis  Media  Purulenta  Acuta, 280 

Otitis  Media  Purulenta  Subacuta, 8 

Total,         . 1,772 

An  analysis  of  these  cases  shows  that  in  393  of  them  the  tonsils 
were  greatly  enlarged  ;  in  6  there  was  [acute  tonsillitis,  in  5  quinsy,  85 
had  acute  rhinitis,  84  chronic  suppurative  rhinitis  (ozsena),  401  were 
markedly  subject  to  recurrent  head  catarrh  (cold  in  the  head),  an  evi- 
dence of  their  special  susceptibility  to  the  usual  exposure  and  vicis.- 
situdes  of  life.  It  has  already  been  mentioned  that  oral  or  dental 
irritation  should  be  regarded  as  occupying  a  causal  relation  to  catarrh 
of  the  upper  air-passages.  Among  these  1,772  cases,  there  were  1,109 
where  oral  irritation  was  found  to  exist.  These  disturbances  were 
due  to  dentition,  caries  of  the  teeth,  and  consequent  alveolar  abscess, 
accumulations  of  tartar,  gingivitis,  glossitis,  aphthae,  and  (in  79  cases) 
to  the  irritation  from  the  wearing  of  vulcanite  and  ill-fitting  dental 
plates. 

Among  the  more  rare  occurrences  was  one  case  of  congenital  fistula 
of  the  larynx,  four  cases  of  abscess  of  Highmore's  antrum,  four  cases 
of  severe  catarrhal  inflammation  of  the  frontal  sinuses,  one  case  of 
necrosis  of  the  hard  palate,  nine  cases  of  gumma  of  the  soft  palate 
with  adhesion  to  the  posterior  wall  of  the  pharynx,  two  cases  of 
gumma  of  the  pharynx,  six  cases  of  cleft  palate,  and  four  cases  of 
other  palatal  anomalies,  with  one  case  of  perforation  of  the  anterior 
pillar.  Ulcer  of  the  pharynx  was  found  in  one  case,  and  adenoid 
growths  in  twenty  cases. 

The  uvula  was  notably  elongated  in  six  cases  (the  moderate  elonga- 
tions were  not  recorded).  Eleven  cases  of  double  uvula  were  seen, 
and  other  anomalies  of  this  organ  existed  in  two  cases.  The  uvula 
was  drawn  to  one  side  in  ten  cases  (marked  instances  only  of  this  not 
unusual  symptom  were  recorded);  it  was  absent  in  one  case.  Very 
marked  deviation  of  the  nasal  septum  was  noted  as  causing  obstruc- 
tion in  twenty-five  cases  and  the  very  general  existence  of  slight  de- 
formity was  noticeable.  The  septum  was  perforated  in  two  cases 
and  absent  in  one.  Excoriation  of  the  nares  was  found  in  two  cases, 
caries  of  the  bones  in  two  cases,  and  nasal  polypus  in  five.     There 


86  CATARRH  OF  THE  UPPER  AIR  TRACT. 

was  deformity  of  the  nasal  organ  in  two  cases  and  arrest  of  develop- 
ment in  one  case. 

Standing  directly  or  indirectly  in  a  causal  relation  to  the  catarrh 
were  85  cases  of  syphilis,  66  of  scarlet  fever,  30  of  measles,  13  of 
diphtheria  (probably  in  some  instances  the  angina  of  scarlatina),  9  of 
bronchitis,  8  of  pulmonary  phthisis,  9  cases  of  laryngitis,  2  of  whooping 
cough,  8  cases  of  "  malaria,"  2  of  typhoid-fever,  and  1  each  of  mumps 
variola,  and  epilepsy.  In  93  cases  there  was  marted  disturbance  due 
to  the  menopause,  pregnancy,  or  some  uterine  disease.  In  20  cases, 
the  occurrence  of  conjunctivitis  (mostly  in  children)  was  observed  to 
occur  along  with  acute  catarrh  of  the  upper  tract.  In  262  cases,  the 
external  auditory  canals  were  the  seat  of  ceruminal  collections,  and  in 
70  cases  there  was  either  circumscribed  or  diffuse  inflammation  of  the 
canals. 

In  one  case,  a  female  aged  64  years,  in  whom  some  deafness  had 
existed  for  twenty  years,  there  had  been,  during  the  past  twelve  years, 
an  increase  of  the  head  catarrh  in  connection  with  suppurative  in- 
flammation of  the  left  superior  maxillary  antrum.  The  carious  tooth 
giving  rise  to  this  complication  was  also  attended  with  alveolar  ab- 
scesses, which  continued  to  form  after  the  pulp  had  been  destroyed 
by  a  dentist,  who,  notwithstanding  its  painfulness,  advised  its  reten- 
tion in  the  jaws.  Deafness  was  observed  to  have  advanced  much  more 
rapidly  on  the  affected  side  (left). 

In  the  case  of  a  male  patient,  28  years  of  age,  deglutition  had  been 
diflScult  and  painful  for  five  months  previously,  and  for  the  past 
month  deafness  had  been  developing.  An  unsuspected  gumma  of  the 
soft  palate  was  found.  The  palate  and  uvula  were  oedematous  and 
there  was  a  thick  viscid  discharge  from  the  nose  and  pharynx  affect- 
ing the  voice.  The  skin  over  the  bridge  of  the  nose  was  much  flushed, 
and  it  was  found  that  the  natural  contour  of  the  organ  was  lost. 

In  the  case  of  a  male  patient,  aged  38  years,  intensely  severe  recur- 
rent attacks  of  head  catarrh  were  attended  with  increased  ceruminal 
secretion.     In  the  following  cases  more  or  less  deafness  existed. 

Case  1. — Army  officer,  age  39  years,  neuropathic  temperament, 
intemperate  and  having  long  suffered  from  a  severe  gun-shot  wound, 
began  suddenly  to  suffer  from  very  severe  recurrent  rhinitis.  The 
right  naris  during  an  attack  becomes  closed  by  the  swelling,  and  he 
experiences  a  sensation  as  though  a  worm  were  "wriggling  about  in 
efforts  to  get  out."  The  drstress  and  nervous  irritability  are  almost 
unendurable.  The  disease  first  showed  itself  sixteen  years  before  and 
at  the  onset  there  was  painfully  persistent  sneezing  which  lasted  for 
eighteen  hours. 

Case  2. — A  female,  aged  28  years,  subject  to  head  catarrh  for  the 


CATAEKH  OF  THE  UPPER  AIR  TRACT.  87 

-past  four  years,  cannot  breatlie  through  the  nose  at  night,  owing  to 
the  accumulation  of  inspissated  muco-purulent  crusts. 

Case  3. — A  male,  aged  17  years,  the  subject  of  head  catarrh,  has 
not  been  able  for  two  years  to  breathe  through  the  nose,  either  while 
waking  or  sleeping.  The  nasal  passages  are  abraded  from  irritation 
with  the  finger  nails  and  painful  to  the  touch.  Crusts  often  accumu:- 
late,  and  the  voice  is  nasal. 

Case  4. — A  female,  aged  44  years,  states  that  seven  years  ago  she 
contracted  the  then  prevalent  epidemic  nasal  catarrh  (epizootic),  suc- 
ceeded by  rhinitis  sicca,  which  has  since  continued  with  loss  of  taste 
and  smell. 

Case  5. — A  female,  3|  years  of  age,  has  very  large  tonsils,  which 
are  so  completely  enveloped  in  the  lateral  half  arches  as  to  be  almost 
invisible.  There  is  chronic  rhinitis,  constant  snuffling,  and  great 
susceptibility  to  head  catarrh.  (Many  cases  of  this  kind  are  seen,  and 
here  the  foundation  of  great  deafness  is  often  laid.) 

Case  6. — A  female,  aged  35  years,  subject  to  qijinsy  sore  throat 
until  her  fifteenth  year,  has  now  purulent  rhinitis  consequent  to 
syphilitic  taint.  Aural  catarrh  and  deafness  has  developed  within 
the  past  few  years. 

Case  7. — Female,  agt.  43  years  (married).  For  past  four  years 
rhinitis  with  much  secretion,  giving  rise  to  constant  hawking.  The 
ears  finally  became  affected.  Subject  to  recurrent  exacerbations 
which  cause  increase  of  her  deafness. 

Case  8. — Male,  5^  years  old,  with  congenital  cleft  palate,  as  has  his 
father  also.  The  tonsils  liave  become  greatly  enlarged  since  an  attack 
■of  diphtheria  (?)  when  the  patient  was  eighteen  months  of  age,  and 
since  having  whooping-cough,  eight  months  ago,  the  difficulty  has 
increased.  The  tonsils,  which  are  of  enormous  size,  meet,  and  breath- 
ing is  difficult,  especially  at  night.  Removal  of  the  tonsils  was 
followed  by  relief. 

Case  9. — Male,  aged  38  years,  contracted  syphilis  sixteen  years  ago. 
Secondary  symptoms  followed,  and  finally  the  nasal  bones  became 
affected.  Two  months  ago  subacute  catarrhal  inflammation  began  in 
the  right  ear. 

Case  10. — Male,  aged  29  years,  says  general  health  and  habits  are 
good  (?),  but  has  had  purulent  rhinitis  sicca  for  most  of  his  life. 
The  pharynx  is  large,  vascular,  aud  thickly  studded  with  adenoid 
developments.  For  past  five  years  has  been  subject  to  acute  catar- 
rhal inflammation  of  both  ears. 

Case  11. — Male,  46  years  of  age,  served  in  Mississippi  Valley  dur- 
ing the  War  of  the  Rebellion  as  assistant  paymaster,  since  which  time 
he  has  been  very  susceptible  to  head  catarrhs.  The  back,  between 
the  shoulders,  is  the  region  of  greatest  sensitiveness,  and  attacks  of 
catarrhal  inflammation  are  usually  ushered  in  or  accompanied  by  such 
disturbances  of  sensation.  The  mucous  membrane  of  the  pharynx  is 
much  thickened  and  covered  by  a  dirty  looking  secretion.  Patient 
hawks  a  great  deal. 


00  CATARRH  OF  THE  UPPER  AIR  TRACT. 

Case  12. — Female,  aged  24  years.  From  draughts  and  other  vicis- 
situdes has  severe  head  catarrh  several  times  each  winter.  The 
invasions  are  marked  by  well-defined  periods;  they  come  on  suddenly 
with  a  down-pour  of  aqueous  fluid  from  the  nose,  lasting  about  three 
days,  irritating  the  outlets  and  excoriating  the  prominent  upper  lip. 
This  is  followed  for  a  period  of  the  same  duration  by  a  feeling  of 
increasing  tightness  of  the  frontal  sinus  region,  causing  great  distress. 
Then  the  "head  breaks,"  and  relief  comes  with  muco-purulent  dis- 
charge of  some  three  days'  duration.  Altogether  a  week  of  severe 
symptoms  is  experienced.  |  ~        ~ 


Case  13.— ^Male,  aged  32.  Neuropathic  temperament;  had  severe 
nasal  catarrh  when  fourteen  years  of  age,  and  since  his  twentieth  year 
recurrences  have  been  frequent.  The  sense  of  smell  is  perverted, 
"  dried  cod-fish  odor''  being  usually  present.  The  mucous  membrane- 
of  the  naso-pharynx  is  a  good  deal  congested,  and  he  has  much  hawk- 
ing. Patient  is  very  susceptible,  taking  "head-cold"  even  when  his- 
hair  is  cut.     The  aural  catarrh  gives  rise  to  much  deafness. 

Case  14. — Male,  aged  29  years.  Neurasthenic  temperament;  has' 
long  had  nasal  catarrh,  but  has  given  no  attention  to  its  treatment. 
Marked  follicular  tonsillitis;  the  distended  crypts  are  filled  with  cheesy- 
exudation.  Patient  is  a  civil  engineer,  and  has  spent  much  time  in 
Colorado,  where  the  alkaline  dust  inhaled  is  very  irritating  to  the  air 
passages.  For  the  past  three  months  the  catarrh  of  the  upper  air- 
tract  has  been  especially  severe,  involving  the  frontal  sinuses.  There 
are  numerous  very  carious  teeth.  It  is  noteworthy  that  this  patient 
was  not  in  any  way  concerned  about  his  condition  until  the  hearing 
became  affected. 

Case  15. — Male,  aged  51  years,  with  an  exceedingly  neuropathic; 
temperament,  served  throughout  the  War  of  the  Eebellion.  In  ad- 
dition to  being  very  nervous,  he  is  subject  to  rheumatism.  Has  been 
anxious  about  his  condition  for  three  years  past,  during  which  time 
treatment  was  directed  to  the  stomach.  Ehinitis  sicca  is  pronounced, 
and  the  aural  catarrh  is  of  the  same  atrophic  nature,  giving  rise  to^ 
distressing  deafness. 

The  records  show  that  catarrh  is  found  equally  as  often  in  the 
blonde  as  in  the  brunette.  In  young  females  with  difficult  or  imper- 
fect menstruation,  the  tendency  to  swelling  of  the  erectile  tissue  of 
the  nose  with  perversion  of  the  sense  of  smell,  and  engorgements  of 
the  tonsils  and  consequent  difficulty  in  swallowing,  or  neurotic  sensa- 
tions in  the  throat  giving  rise  to  choking  sensations,  were  so  often 
met  with  as  to  be  regarded  as  of  the  greatest  significance.  Such 
persons  were  exceedingly  liable  to  acute  purulent  inflammation  of  the 
ears.  Among  the  intemperate  syphilitic  subjects,  rhinitis  sicca  and 
purulent  otitis  media  with  tendency  to  collections  of  desiccatei 
muco-pus  in  the  middle  ear-tract,  were  notably  associated  together. 


CHAPTER     Til. 

ORAL    lERITATION. 

Dentition,  Caries  of  the  Teeth,  etc. — The  sympathetic  nervous  con- 
nection between  the  ears  and  other  organs  has  long  been  known;  thus 
Hieron.  Mercurialis  states  in  one  of  the  earliest  monographs  on  the 
eye  and  ear,  in  speaking  of  the  latter,  that  scratching  the  ears  ex- 
cites coughing  {" primo  qtda  si  aures  scalpantur,  protinus  excitatur 
tussis").^  The  celebrated  anatomist,  Du  Verney,  however,  whose 
well-known  treatise  on  the  ear  was  published  in  1683,  makes  no  allu- 
sion to  the  nervous  relationship  between  the  teeth  and  ears.  Our 
attention  was  specially  drawn  to  the  subject  by  the  writings  of  Dr. 
Cooper,''  whose  article  on  the  difficult  eruption  of  the  wisdom  teeth 
is  very  instructive. 

Both  the  eruption  and  decay  of  the  teeth  give  rise  to  greater  or  less 
local  irritation  in  the  gums,  a  region  richly  supplied  with  blood-ves- 
sels and  nerves,  and,  as  before  stated,  there  is  reason  to  believe  that 
even  in  the  embryonic  state  premature  activity  in  the  deciduous 
teeth,  causing  reflex  disturbance,  may  give  rise  to  irritation  in  the 
gums.  We  find  the  ear  very  often  affected  by  sympathetic  dental  ir- 
ritation in  infancy  from  the  time  of  the  appearance  of  the  two  cen- 
tral incisors  of  the  lower  jaw,  which  are  cut  at  about  the  seventh 
month,  until  the  completion  of  the  first  dentition  at  about  the  end  of 
the  second  year.  The  local  disturbance  during  the  eruption  of  these 
teeth  is  sometimes  truly  alarming,  even  periostitis  of  the  jaw  occur- 
ring in  the  more  severe  cases. 

The  deciduous  teeth  are  extremely  fragile  in  children  of  low  vital- 
ity, and  decay  very  rapidly;  they  frequently  give  rise  to  toothache 
and  earache  at  the  same  time.  The  shells  of  temporary  teeth  found 
imbedded  in  the  gums  long  after  absorption  of  their  roots  are  liable 

^  Tractatus,  etc.  (De  Aurium  Affectibus  prselectiones),  "Venice,  1590,  pp. 
51-52. 

^  Clinical  Lectures  upon  Inflammation  and  Other  Diseases  of  the  Ear,  Lon- 
don, 1878,  pp.  99-104. 


'90 


ORAL    IRRITATION. 


to  cause  irritation,  and  should,  therefore,  be  removed.  Such  is  the 
nervousness  of  teething  children  that  they  are  seldom  free  from  head 
colds  in  consequence  of  their  great  susceptibility.  The  irritation 
created  iu  the  gums  of  infants  during  dentition  will  often,  on  exami- 
nation, be  found  to  have  caused  more  or  less  hyperaemia  in  the  ears 
^here  attention  has  not  been  directed  to  the  aural  region  by  earache. 
Even  purulent  otitis  is  often  well  established  before  the  physician  is 


Fio.  16.— Casts  of  the  Teeth  of  a  School-girl,  Twelve  Years  of  Age.' 

The  casts  are  represented  as  being  held  together  by  a  hinge.  1,  1,  The  second  bicuspid  teeth 
of  the  upper  jaw,  both  of  which  have  been  crowded  out  of  place  as  they  erupted  by  the  remains 
of  the  fangs  of  the  temporary  second  molar  teeth ;  these  fangs,  which  have  been  too  long  re- 
tained in  the  gums,  are  seen  in  the  cut  just  inside  the  second  bicuspids.  The  retention  of  the 
fangs,  together  with  the  crowded  and  irregular  condition  of  the  permanent  teeth  which  have 
just  been  cut,  gave  rise  to  much  irritation.  This  anomalous  condition  of  the  teeth  is  by  no 
means  an  unusual  occurrence  where  the  teeth  are  neglected.  2,  The  left  upper  six -year  molar 
tooth,  which  is  very  carious.  3,  3,  The  two  lower  sbc-year  molars,  both  of  which  have  been  de- 
stroyed by  caries.  The  little  girl  from  whose  teeth  these  casts  were  taken  suffered  from  deaf- 
ness and  frequent  attacks  of  pain  in  both  ears,  and,  as  she  herself  expressed  it,  "  the  decayed 
teeth  had  ached  very  much  all  around." 


*  The  author's  collection  of  170  plaster  casts  of  the  teeth  from  which  the 
accompanying  three  cuts  were  selected,  is  now  in  the  Army  Medical  Museum, 
in  Washington  ;  a  descriptive  catalogue  of  them  has  been  prepared  by  the 
Surgeon-General's  Office  for  publication. 


ORAL    IRRITATION. 


91 


consulted;  and  deafness  being  difficult  of  detection  at  an  early  age, 
some  cases  become  deaf  and  dumb  before  any  symptom  has  specially 
directed  attention  to  the  ear.  The  physiological  progress  of  denti- 
tion may  take  place  without  any  severe  reflex  disturbances,  but  the 
evolution  of  the  dental  germs  often  assume  a  pathological  interest. 


Fig.  17.— View  of  Plaster   Casts  op  the   Upper  and    Lower  Teeth  of  a  Youth    Aged 

Twenty-two  Yhiars. 


and  grave  cerebral  irritation  may  ensue,  complicating  very  much  the 
diagnosis  of  acute  aural  disease  so  common  in  infancy. 

Second  Dentition. — This  commences  between  the  end  of  the  fifth 
or  the  beginning  of  the  seventh  year.     As  the  first  molars  of  the  per- 


92  ORAL   IRRITATION. 

manent  teeth  come  through  the  gums  at  about  the  sixth  year,  the' 
milk  teeth,  together  with  their  alveoli,  suffer  re-absorption.  Second 
dentition  is  concluded  (with  the  exception  of  the  wisdom  teeth)  by 
the  cutting  of  the  second  permanent  molars  at  the  twelfth  or  thir- 
teenth year,  the  rest  of  the  permanent  teeth  coming  gradually  in  as 
the  temporary  set  falls  out.  The  permanent  teeth  are,  like  their 
predecessors,  liable  to  be  attacked  by  caries  as  soon  as  they  are  cut. 
The  first  of  this  series,  called  the  first  or  *' six-year"  molar,  is  spe- 
cially disposed  to  decay  as  soon  as  it  comes,  since  during  its  eruption 
there  is  generally  much  irritation  in  the  jaws  from  the  other  teeth, 
besides  the  occurrence  of  systemic  malnutrition  during  the  exan- 
themata of  childhood,  etc.  Under  these  unfavorable  influences,  it  is 
imperfectly  developed,  and  hence  very  susceptible  to  the  usual  causes 
of  decay.  It  is,  furthermore,  generally  thought  that  this  tooth  be- 
longs to  the  temporary  set,  and  no  notice  is  taken  of  it  until  pain 
results  from  exposure  of  the  pulp  cavity,  caused  by  excessive  decay. 

During  the  first  and  second  dentitions  the  mouth  has  but  little 
rest.  The  whole  period  of  the  first  is  frequently  an  uninterrupted 
painful  process,  which  is  rapidly  followed  by  the  steady  advance  of 
the  second  teeth,  whose  early  decay  is  imminent.  To  this  must  bo 
added  the  irritation  of  adherent  fragments  of  the  milk  teeth,  and  the 
not  infrequent  anomalies  of  development,  neglect  of  cleanliness  of 
mouth,  collections  of  tartar,  and  tbe  presence  of  abnormal  saliva. 

Aural  affections  that  have  arisen  from  the  sympathetic  irritation  of 
the  first  dentition  are,  in  many  instances,  no  sooner  cured  than  they 
are  again  aroused  into  sudden  activity  by  the  cutting  of  the  second 
teeth,  the  eruption  of  each  tooth  often  being  the  signal  for  an  ear- 
ache and  subsequent  otorrhcea. 

During  the  period  of  the  eruption  of  the  second  teeth  the  educa- 
tion of  the  child  begins,  and  to  the  mental  strain  to  which  he  is  often 
subjected  at  this  period  of  life,  the  general  nervous  exhaustion  so 
often  seen  is  due.  Thus  run  down  from  mental  overwork  and  the 
irritation  in  the  jaws,  he  is  much  more  subject  to  catarrhal  invasions 
of  the  air-tracts,  and  of  the  middle-ear  particularly,  because  of  its 
liability  to  reflex  hyperaemia.  There  are  but  few  persons  who  pass 
through  the  period  of  childhood  without  having  at  some  time  expe- 
rienced an  earache  from  this  source. 

The  Wisdom  Teeth. — These  usually  erupt  between  the  sixteenth 
and  eighteenth  year,  but  they  often  are  delayed  for  five  or  ten  years,  and 
those  of  the  lower  jaw  in  many  instances  come  into  place  with  great  dif- 
ficulty even  when  erupted  earlier.  The  wisdom  teeth  sometimes  re- 
main beneath  the  gum  during  life,  the  natural  expulsive  force  havings 


OEAL    IRRITATION. 


93 


seemingly,  become  exhausted.  They  very  often  are  found  in  the 
lower  jaw  in  a  partially  erupted  state,  presenting  their  crowns 
against  the  neck  or  crown  of  the  adjacent  second  molar  tooth,  and 
being  urged  onward  in  the  process  of  erupting,  cause  very  great  irri- 
tation. Sometimes  the  coming  of  these  teeth  gives  rise  to  prosopal- 
gia, abscesses  in  the  gums,  inflammation  of  the  tonsillar  region,  and 
even  necrosis  of  the  jaws  ultimately.  The  author  has  seen  cases 
of  protracted  tonsillitis  and  also  inflammation  of  the  connective  tis- 
sue of  the  pharynx  generally  from  this  cause,  where  irritation  about 
the  erupting  tooth  itself  was  not  a  marked  feature  and  was  liable 
to  be  overlooked  entirely. 


Fig.  18.— Lower  Jaw  or  Inferior  Maxilla,  from  a  Specimen  in  the  Author's  Possession, 

The  figure  shows  the  horizontal  position  of  the  lower  wisdom  teeth,  the  position  which  gives  rise 
to  their  difficult  eruption.  1,  The  right  wisdom  tooth,  which  is  wedged  in  between  the  ramus,  or 
upright  portion  of  the  jaw,  and  the  second  molar  tooth;  it  has  not,  as  yet,  been  able  to  leave 
its  socket  and  cut  through  the  gum.  As  the  tooth  is  urged  onward  in  the  effort  to  erupt,  it  is 
forced  against  the  sensitive  root  of  the  neighboring  tooth,  the  pressure  giving  rise  to  much 
irritation.  2,  The  fully  erupted  left  wisdom  tooth;  it  is  inclined  toward  the  first  molar;  the 
second  molar  on  this  side  having  been  lost,  room  was  afforded  this  tooth  to  cut  through  the  gum. 

Some  of  the  most  protracted  and  intractable  cases  of  acute  puru- 
lent inflammation  of  the  middle  ear  that  the  author  has  ever  seen 
have  been  associated  with  the  cutting  of  a  wisdom  tooth,  the  reflex 
dental  irritation  keeping  up  the  aural  trouble. 

In  consequence  of  the  less  marked  aural  irritation  excited  through 
nervous  sympathy  in  the  more  protracted  cases,  subacute  and  chronic 
catarrh  of  the  middle  ear,  giving  rise  to  extreme  deafness,  may  come 


94 


ORAL    IRRITATION. 


on  SO  gradually  that  the  patient  is  unaware  of  its  existence  until  its 
progress  lias  been  marked. 

Cases  are  recorded  where  these  teeth  have  made  their  appearance  in 
persons  as  late  as  sixty  years  of  age.  Should  the  throat  be  involved, 
as  indeed  it  is  likely  to  be,  in  these  cases  of  difficult  dentition,  the 
ears  will  be  found  to  be  affected  through  other  channels  than  the 
irritation  of  the  dental  filaments  of  the  fifth  nerve,  for  the  pharyngeal 
and  tonsillar  branches  of  the  eighth  cranial  nerve  will  bring  the 
throat  into  direct  relationship  with  the  sympathetic  system  through 
which  the  ear  is  affected. 


Fig.  19.— Front  View  of  Plaster  Casts  Representing  the  Teeth  or  A  Boy  Aged 

Seventeen. 

Reflex  aural  irritation  long  continued  may  establish  an  inflamma- 
tion the  etiology  of  which  will  be  obscure,  especially  if  the  patient 
has  been  exposed  to  well  recognized  causes  of  aural  disease,  unless  the 
part  taken  by  the  teeth  be  kept  in  mind.  The  pain  of  the  teeth, 
which  we  familiarly  associate  with  their  inflammatory  condition,  is 
signally  absent  in  many  of  their  affections,  and  it  is  the  absence  of 
this  symptom  that  gives  rise  to  the  chief  cause  of  danger. 

The  buccal  mucous  membrane,  likewise,  becomes  diseased  from  the 
sharp  points  of  the  teeth,  which  cause  its  ulceration.  Alveolar  ab- 
scess, affections  of  the  antrum  of  Higlimore  and  nose  are  common 


ORAL   IRRITATION.  95"' 

occurrences  in  consequence  of  death  of  the  pulp  of  the  teeth.  Irrita- 
tion from  concealed  fangs,  left  on  extraction,  or  after  decay  of  the 
rest  of  the  root,  is  frequent,  and  from  this  source  irritation  or  neur- 
algias arise,  in  which  the  ear  participates  in  numerous  instances. 

The  presence  of  collections  of  tartar  gives  rise  to  irritation,  as  may 
be  seen  by  the  denudation  of  the  roots  of  teeth  which  they  occasion; 
a  line  of  gum  much  redder  than  normal  may  thus  be  formed,  and,  in 
numerous  cases,  the  gums  around  temporary  or  permanent  teeth 
finally  take  on  a  suppurative  action.  Crowding  of  irregular  teeth 
also  gives  rise  to  nervous  irritability. 

From  the  writer's  own  observations,  he  is  convinced  that  the  result; 
of  transmitted  irritation  of  the  dental  filaments  of  the  fifth  pair  tO' 
the  aural  region  often  gives  rise  to  diseases  of  the  external  auditory 
canal,  as  seborrhoea,  diffuse  and  circumscribed  inflammation,  as  well 
as  inflammation  of  the  middle  ear.  It  should  be  stated,  furthermore,, 
that,  according  to  Burnett,'  reflex  ulceration  of  the  canal  from  these 
causes  is  not  an  upcommon  occurrence.  In  one  instance,  the  impulses 
transmitted  to  the  ear  may  give  rise  to  otalgia,  wliilst  on  the  other 
hand,  their  long  continuance  may  cause  vessel  dilatation  and  conse- 
quent congestion  in  the  nutrient  tract,  ultimately  giving  rise  to  pro- 
gressive trophic  changes,  in  their  nature  chronic.  It  is  a  significant 
fact  that  the  sympathetic  aural  affections  of  infancy  and  youth  are 
principally  confined  to  the  middle  ear;  and  it  should  be  borne  in 
mind  that  the  entire  nervous  distribution  for  the  milk  teeth,  to- 
gether with  their  alveoli,  etc.,  give  way  to  another  development  be- 
longing to  the  teeth  that  are  destined  to  be  permanent. 

Dental  Plates  and  Fillings. — It  has  been  endeavored  in  the  forego- 
ing pages  to  show  in  a  general  way  some  of  the  injurious  influences 
that  diseased  teeth  have  on  the  ear.  It  now  remains  to  consider  the 
no  less  important  ones  that  arise  from  the  attempts  made  to  preserve 
them,  or  replace  them  when  lost,  by  artificial  devices.  Cavities  in 
the  teeth  are  filled  with  a  variety  of  substances  when  the  ravages  of 
caries  become  manifest.  The  most  universally  used  filling,  except- 
ing perhaps  gold,  is  an  amalgam  consisting  of  about  two  parts  of 
tin,  one  of  silver,  and  as  much  mercury  as  will  cause  the  mass  to  ad- 
here together.  This  amalgam,  composed  so  largely  of  mercury,  is 
usually  much  exposed  to  the  attrition  of  mastication  and  the  move- 
ments of  tongue  and  cheeks.  Fillings  badly  adapted,  or  where  much 
oxidized  by  exposure,  are  liable  to  produce  harmful  results.  The 
free  mercury  which  this  amalgam  contains  is  worn  off  in  small  par- 

1  Treatise  on  the  Ear,  Philadelphia,  1884,  page  800. 


96  ORAL   IKRITATION. 

tides  by  the  friction  of  the  mouth.  These  particles,  when  submitted 
to  dilute  hydrochloric  acid,  yield  a  chloride  of  mercury.  That  toxic 
effects  may  result  from  wearing  a  considerable  number  of  these  fill- 
ings in  the  teeth  is  to  be  feared.  Of  fillings  in  general,  it  may  be- 
said  that,  not  unfrequently,  necrosed  matter  or  a  diseased  dental  pulp 
are  covered  up  with  fillings,  inducing  great  irritation  from  the  con- 
fined products  of  inflammation  or  decomposition.  Mechanical  appli- 
ances to  the  teeth  are  not  always  intended  solely  to  serve  the  purpose 
of  stopping  cavities,  for  mechanical  skill,  in  a  certain  branch  of  den- 
tistry, has  made  it  possible  for  the  operator  to  permanently  attach 
gold  or  amalgam  mounts  to  teeth  in  such  a  manner  as  to  supply  very 
useful  substitutes  for  the  crowns  which  have  been  destroyed  by  caries. 
Dental  artifices  are  not  altogether  harmless,  when  continuously  worn 
in  the  mouth,  especially  by  run-down  or  nervous  subjects,  since  they 
often  give  rise  to  much  irritation.  Whilst  the  author  does  not  recom- 
mend that  all  pulpless  ("dead")  teeth  should  be  removed,  he  still  be- 
lieves that  in  many  instances,  perhaps  in  the  greater  number,  they 
cannot  be  retained  without  injury  to  the  patient;  in  his  aural  prac- 
tice, he  has  observed  a  great  many  recoveries  quickly  following  the 
removal  of  defective  teeth. 

Artificial  teeth  are  worn  by  an  exceedingly  numerous  class,  and  it  is 
believed  that  health  often  is  imperilled  by  the  material  used  in  the 
construction  of  plates,  as  well  as  from  illy  fitting  them  to  the  mouth. 
This  subject,  therefore,  should  be  of  interest  to  the  profession  at 
large,  as  well  as  the  specialist.  Plates,  especially  the  vulcanite,  are 
frequently  put  into  the  mouth  over  carious  fangs,  inflamed  gums, 
and  collections  of  tartar,  completely  incasing  diseased  structures,  and 
thereby  retaining  the  foul  secretions  and  decomposed  particles  of 
food  usually  present.  Upper  plates  are  especially  obnoxious  under 
these  circumstances.  Many  cases  have  come  under  the  observation  of 
the  author,  where  dentists  have  recommended  them  to  wear  their 
plates  day  and  night,  in  order  to  accustom  themselves  to  their  pres- 
ence; and  where  plates  have  been  inserted  in  the  mouth  as  soon  as 
the  defective  teeth  were  extracted;  these  plates  are  constantly  found 
in  the  mouth  as  described  above,  without  pain  or  apparent  inconve- 
nience to  the  wearer,  owing  to  the  tolerance  acquired  by  long  use. 
That  septic  poisoning  may  occur  from  absorption  when  pus  is  con- 
fined beneath  dental  plates  is  possible. 

Gold,  platinum,  and  vulcanite  are  the  principal  substances  used 
in  the  construction  of  plates.  Silver  and  celluloid  are  also  used 
sometimes.  Vulcanite  plates  produce  diseases  that  are  more  fre- 
quently the  source  of  reflex  aural  troubles  than  any  of  the  others 


ORAL    IRRITATION. 


97 


worn.  The  constituents  of  this  material  are  caoutchouc,  the  sulphur 
required  in  the  vulcanizing  process,  and  vermilion  or  the  sulphide  of 
mercury,  used  for  the  color  it  imparts. 

Experiments  show  that  this  plastic  substance,  before  it  is  submitted 
to  the  vulcanizing  process,  when  chewed  for  several  hours,  is  so 
much  broken  up  that  it  parts  with  the  vermilion,  and  that  when  the 
saliva  of  persons  thus  chewing  it  was  treated  with  a  suitable  re- 
agent, it  yielded  a  salt  of  mercury.  Vulcanite  is  a  non-conductor 
of  heat,  and  the  effect  of  its  contact  with  the  highly  sensitive  tissue 
of  the  mouth  is  often  to  produce  hyperaemia  and  inflammation. 
When  the  plates  are  worn  day  and  night,  of  course  their  injurious  ef- 
fects are  much  greater.  Celluloid  has  been  brought  forward  as  a 
substitute  for  vulcanite  in  the  construction  of  plates,  but  this  sub- 
stance has  not  been  adopted  to  any  great  extent.  That  all  of  the 
morbid  conditions  of  the  mouth  above  described  may  exist  without 
serious  or  recognizable  aural  affection  cannot  be  denied;  but  pro- 
gressive disease  of  the  ears,  often  without  the  occurrence  of  pain,  is, 
in  the  author's  experience,  more  common  when  these  oral  affections 
are  present  than  when  the  mouth  and  throat  are  in  a  healthy  state. 

These  conclusions  of  the  author  are  drawn  from  the  carefully  re- 
corded observations  of  some  eighteen  hundred  cases  of  aural  disease, 
in  which  the  symptoms  of  reflex  irritation  from  diseased  teeth  were 
especially  severe.  The  table  below  gives  the  ages  and  sex  of  these 
cases. 


AOB. 


Under  3  years 

3  years  to  6  years . . 
6  years  to  12  years  . 
12  years  to  ^1  years 
21  years  to  40  years 
40  years  to  60  years 
Over  60  years 

Tt>tal 


Males. 


Females. 


30 

25 

55 

20 

45 

65 

91 

115 

206 

144 

137 

281 

394 

811 

705 

230 

169 

899 

59 

29 

88 

831 


Total. 


1,799 


As  will  be  observed  in  the  above  table,  but  55  cases  were  under  3 
years  of  age.  It  will  be  proper  to  state  here  that  all  the  cases  above 
given  were  such  in  whom  the  symptoms  were  very  marked,  and  of 
which  it  was  deemed  advisable  to  keep  a  record.  The  ages  and  sex 
of  the  55  cases  under  the  age  of  3  years  were  as  follows: 
7 


^8 


ORAL    IKRITATION. 


Age. 

Males. 

Feuales. 

Total. 

7  months  and  under 

8  months 

6 
8 
1 

ii 

9 
80 

2 

i 

1 

2 

10 

9 

25 

8 
8 

9  months 

3 

10  months 

1 

1 1  months 

2 

Between  1  and  2  years 

21 

Between  2  and  3  years 

Total 

18 
55 

Among  the  aural  diseases  associated  with  these  cases  of  diseased 
teeth,  due  undoubtedly  in  a  great  measure  to  reflex  irritation  from 
this  source,  were  93  cases  of  acute,  33  of  subacute,  and  688  of  chronic 
catarrhal  inflammation  of  the  middle  ear.  There  were  235  cases  of 
acute,  4  of  subacute,  and  401  of  chronic  purulent  inflammation  of  the 
middle  ear.  Of  diffuse  and  circumscribed  otitis  externa  (furuncu- 
losis)  there  were  102  cases,  and  340  cases  of  large  accumulations  of 
cerumen,  41  cases  of  seborrhoea,  and  24  cases  of  eczema.  There  was 
severe  purulent  inflammation  of  the  middle  ear  involving  the  mas- 
toid cellules,  etc.,  in  26  cases.  In  953  cases  there  was  marked 
catarrh  of  the  upper  air  tract,  this  group  including  also  a  considera- 
ble number  of  cases  of  enlarged  tonsils,  52  cases  of  alveolar  abscess, 
and  21  cases  of  ozaena.  The  tendency  to  catarrh  of  the  entire  upper 
air  tract  is  doubtlessly  much  increased  in  persons  having  defective 
teeth. 

Of  189  dental  plates  worn  by  these  patients,  178  were  composed 
of  vulcanized  rubber,  3  of  'gold,  3  of  platinum,  1  of  silver,  4  of 
celluloid. 

A  table  of  the  ages  and  sex  of  patients  wearing  vulcanite  plates 
given  below. 


AOE. 


Males. 


Females. 


Total. 


Under  20  years 
20  to  30  years. . 
80  to  40  years. , 
40  to  50  years. 
50  to  60  years. . 
Over  60  years. . 

Total.... 


1 

10 

11 

10 

9 

8 

49 


5 
36 
31 
32 
16 

9 

129 


6 

46 
42 
42 
25 

17 

178 


ORAL   IRRITATION.  99 

Of  tlie  11  remaining  cases  where  other  kinds  of  plates  were  worn, 
2  were  males,  9  females. 

It  is  often  urged  as  a  reason  for  wearing  artificial  teeth  or  retaining 
dead  teeth  by  filling  more  or  less  completely  the  pulp  chamber  and 
fangs  of  teeth,  that  the  absence  of  even  a  few  teeth  prevents  the 
thorough  mastication  of  food,  and  that  its  digestion  is  thus  interfered 
with.  The  importance  of  the  teeth  in  this  respect  is  greatly  over- 
estimated, as  the  many  changes  in  the  kinds  of  food  and  their  prepa- 
ration in  the  present  state  of  civilization  have  very  materially  less- 
ened the  necessity  for  mastication  by  the  teeth.  These  plates  are 
very  commonly  worn  by  persons  among  the  serving  class,  who  plead 
in  excuse  that  it  is  difficult,  if  not  quite  impossible,  to  secure  situa- 
tions on  account  of  their  personal  appearance  where  the  front  teeth 
are  absent.  Their  means  do  not  admit  of  the  purchase  of  other  than 
cheap  and  ill-fitting  false  teeth,  which  are  very  often  positively  inju- 
rious to  the  wearer. 

The  harm  liable  to  result  from  the  retention  of  dead  teeth  in  the 
mouth  cannot  well  be  exaggerated,  especially  where  the  nerve  cavi- 
ties are  stopped,  and  no  vent  exists  for  the  escape  of  accumulations 
which  form  in  them.  The  retention  of  pulpless  teeth  should  be 
avoided,  especially  in  persons  wanting  in  nervous  tone.  The  con- 
stant hyperaemia  thus  often  kept  up  in  the  organ  of  hearing  by  reflex 
oral  irritation  renders  the  ear  less  able  to  withstand  the  influence  of 
other  active  outside  agents  and  more  prone  to  disease;  for  example, 
it  was  found  that  among  the  very  considerable  number  of  cases  of 
oral  irritation  observed,  in  79  having  very  much  decayed  teeth,  the 
direct  cause  of  the  ear  trouble  was  due  to  getting  water  in  the  ears 
while  bathing  in  the  sea,  in  one  instance  to  fresh-water  bathing,  and 
in  another  to  a  shower  bath.  It  was  noted  that  severe  neuralgia  was 
present  in  179  cases,  pronounced  nervous  irritability  in  21  cases,  nasal 
and  other  reflex  phenomena  in  20  cases,  and  severe  otalgia  in  59 
cases. 


CHAPTER    Tin. 

Bathing  in  the  sea.     Fresh  water  bathing.  Russian,  Turkish,  and  other 

baths.    Entrance  of  water  into  the  ears  by  the  use  of  the  Nasal  Douche, 

Post-nasal  syringe,  SniflSng  up  of  water,  etc.  Clipping  and  wetting  the  hair 
of  the  head. 

INJURY  TO  THE  EAR  FROM   BATHING, 

The  entrance  of  water'  into  the  ear  was  known  to  be  injurious  by 
the  ancients,  since  Avicenne,  a  Persian  physician  of  the  tenth  century, 
enumerates  among  the  causes  of  aural  disease  "  getting  water  into  the 
ear."  '  It  is  a  matter  of  surprise  that  such  a  common  source  of  ear 
trouble  should  have  attracted  so  little  attention  among  modem 
writers,  especially  those  living  near  the  ocean,  where  large  numbers  of 
persons  go  into  the  water  daily  during  the  bathing  season.  But  be- 
fore entering  into  an  account  of  the  manner  in  which  the  ears  of 
bathers  are  affected,  it  will  be  of  interest  to  consider  the  construction 
of  the  ear  in  animals  living  a  portion  of  the  time  submerged  in  water, 
A  large  number  of  marine  quadrupeds  may  be  included  in  this  class. 
Buch  as  the  crocodile,"  seal,  hippopotamus  and  the  like.  These  can 
remain  under  water  a  long  time  before  coming  to  the  surface  for  the 
purpose  of  breathing,  and  it  is  found  that  the  construction  of 
their  ears  is  such  that  no  damage  occurs  to  the  organ  from  frequent 
excursions  into  the  water,  which  is  frequently  colder  than  the  atmo- 
sphere as  well  as  irritating  to  delicate  structures.  A  study  of  the  hip- 
popotamus amphibius,  or  river-horse,  in  this  regard  is  instructive. 
The  author  has  often  observed  this  pachydermatous  monster  during 
his  aquatic  sports  in  the  large  tank  of  water  provided  for  his  use  at 
the  Zoological  Garden  in  Central  Park.  When  inclined  to  retire  into 
the  aqueous  element,  the  animal's  body  first  disappears,  leaving  the 
head  in  view.  If  his  actions  be  now  closely  observed,  it  will  be  seen 
that  the  ears,  eyes,  and  nostrils,  which  lie  on  about  the  same  plane, 

\Works  of  Avicenne.     Basle,  1556. 

*  Miall:  The  Skull  of  the  Crocodile.    Macmillan  &  Co.,  London,  1878. 


INJURY    TO    THE    EAR    FROM    BATHING.  101 

are  immersed  at  nearly  the  same  moment.  As  the  head  is  gradually 
lowered  the  auricle  is  given  a  twist  and  drawn  down  closer  to  the  head; 
the  eyes  are  then  closed  and,  finally,  as  the  nose  goes  under,  the  nos- 
trils are  closed  by  the  action  of  a  sphincter  muscle.  When  the 
animal  comes  to  the  surface  again,  the  nose  first  appears  and  an  ex- 
piratory effort  takes  place,  blowing  a  little  moisture  from  the  parts  ; 
the  eyes  are  opened  again,  and  the  auricles  are  brought  smartly  up, 
opening  the  external  meatus  and  throwing  a  gentle  spray  from  their 
surface.  These  functions  are  seemingly  performed  automatically. 
Some  of  the  animals  of  this  class  are  provided  by  nature  with  a 
movable  membrane  which  can  be  drawn  over  the  ears  when  diving 
under  water,  and  they  always  close  the  mouth  and  nostrils.  The 
water  shrew  is  said  to  protect  the  ears,  when  pursuing  game  into 
water,  by  closure  of  the  meatus,  which  is  accomplished  by  muscular 
force  exerted  in  such  a  manner  as  to  also  draw  the  meatus  inwards. 
The  auditory  apparatus  of  the  whale  is  said  to  be  protected  by  the 
smallness  of  the  external  auditory  meatus,  which  begins  externally 
with  a  narrow  opening,  arid  finds  its  way  to  the  drum  by  a  long,  tor- 
tuous, tubular  passage.  It  has  been  alleged'  that  it  is  impracticable 
for  sound  vibrations  to  reach  the  drum-head  through  a  canal  so  narrow; 
that  indeed  the  drum-head  is  convex  outwardly — the  opposite  condi- 
tion to  that  in  man  and  other  mammalia — whilst  the  Eustachian  tube 
is  so  large  as  to  suggest  the  entrance  of  sound  through  the  mouth 
when  open  ;  the  author,  however,  doubts  the  correctness  of  the 
foregoing  conclusion. 

Some  of  the  lower  orders  of  marine  life,  living  exclusively  in  water, 
have  no  special  auditory  nerve,  but  receive  sound  impressions  by 
means  of  shock  imparted  to  the  body. 

The  tympanic  membrane  and  other  parts  necessary  to  sound  trans- 
mission in  mammalia  are  said  to  be  absent  in  snakes  and  many  saurians, 
though  lizards  and  frogs  have  an  exposed  drum-head.  Moles  are  said 
to  have  a  closed  external  auditory  meatus  which  excludes  earth  in 
burrowing  f  and  the  camel  when  exposed  to  the  sand  laden  simoon 
of  the  desert  has  the  ability  to  contract  the  nostrils  at  will. 

It  will  be  seen  from  the  foregoing  that  the  ears  of  amphibia  are 
naturally  adapted  to  the  circumstances  of  their  environments.  Man, 
however,  unlike  amphibians,  has  not  the  peculiar  anatomical  struc- 
ture, by  means  of  which  water  may  be  automatically  shut  out  from 
the  auditory  apparatus  when   his  head   is  submerged,  and  the  fre- 

'  Pilcher. 

-  Bergman  and  Ijeuckart :  Vergleichende  Anatomie  und  Physiologie.  Stutt- 
gart, 1852. 


102  INJURY   TO   THE    EAR   FROM   BATHING. 

quency  of  aural  disease  from  bathing,  especially  in  the  ocean,  justifies 
the  considerable  space  which  will  be  devoted  to  the  subject  here. 

Bathers  in  the  surf  are  liable,  when  off  their  guard,  to  be  struck  by 
the  waves  upon  the  ear  with  much  violence,  especially  in  boisterous 
water  at  full  tide.  Cold  salt  water  may  thus  enter  the  external  audi- 
tory canal  with  sufficient  momentum  to  rupture  the  drum-head  in 
persons  having  a  large,  freely  open  canal.  Swimming  or  floating  upon 
the  back,  especially  the  latter,  when  the  ears  are  submerged,  or  diving 
and  swimming  beneath  the  surface,  often  exposes  the  ears  very  much 
to  the  .entrance  of  water.  Long  exposure  in  this  manner,  and  indeed, 
sometimes  from  a  bath  of  short  duration,  frequently  gives  rise  to  in- 
flammation of  the  external  auditory  canal  or  the  drum-head,  or  of  both. 
In  a  considerable  number  of  cases  the  middle  ear  is  also  invaded. 
Some  of  the  more  severe  cases  of  otitis  media  arise  from  the  long  re- 
tention of  cold  and  irritating  salt  water  in  the  external  auditory  canal, 
the  inner  end  of  the  latter,  from  its  more  dependent  position,  afford- 
ing lodgment  for  the  same.  Every  bather  has  experienced  the  disa- 
greeable sensation  arising  from  "  getting  water  in  the  ears,"  which  is 
not  always  removed  by  jumping  about  on  one  foot  with  the  ear  held 
downwards.  The  cold  water  of  the  sea  is  especially  obnoxious  because 
of  its  comparatively  uniform  low  temperature  and  the  large  quantity 
of  chloride  of  sodium  which  it  holds  in  solution  ;  it  thus  injures  the 
ear  by  a  direct  cooling  effect  as  well  as  by  its  highly  irritating  char- 
acter. 

When  the  face  is  struck  by  a  violent  wave,  the  water  sometimes  has 
sufficient  momentum,  after  entering  the  open  mouth  or  nostrils,  to 
force  its  way  along  up  the  Eustachian  tube  to  the  middle  ear. 
The  violence  of  the  impact  of  an  ocean  wave  cannot  be  fully  appre- 
ciated by  any  one  who  has  not  felt  its  force ;  it  is  often  sufficient  to 
knock  the  most  sturdy  bather  off  his  feet  and  mercilessly  toss  him 
about  in  the  sand  and  foam  of  the  breakers.  The  author's  own  expe- 
rience in  rough  water  has  very  much  impressed  him  with  the  danger 
to  the  ear  from  this  cause.  Persons  unguardedly  sporting  in  the 
water  are  never  free  from  danger  in  this  regard,  and  in  diving  or 
struggling  in  the  surf  may  take  into  the  mouth  or  nose  a  large 
enough  quantity  of  water  to  cause  strangling,  the  act  being  accom- 
panied by  the  transmission  of  more  or  less  water  into  the  drum  of  the 
ear.  The  habit  of  standing  in  the  cool  wind  while  the  body,  and  es- 
pecially the  hair  of  the  head,  is  allowed  to  slowly  dry  by  evaporation, 
is  reprehensible,  as  is  also  the  practice  of  blowing  the  nose  forcibly 
with  a  view  to  clearing  its  passages  of  sea  water  ;  the  former  is  liable 
to  invite  head  colds,  the  latter  may  force  sea  water  into  the  drum. 


INJTJRY   TO   THE   EAR    FKOM   BATHING. 


103 


Men  are  much  more  exposed  to  the  causes  above  mentioned  than  are 
women. 

The  following  tabulated  list  of  273  cases  of  aural  disease  arising 
from  salt-water  bathing  shows  the  sex  of  the  patients  and  also  the 
ages  in  which  these  troubles  are  most  liable  to  occur. 


Age. 


Under  5  years 

Between  5  and  10  years. 
Between  10  and  20  years 
Between  20  and  30  years 
Between  30  and  40  years 
Between  40  and  50  years 
Over  50  years 

Total 


Maxes. 


2 

112 

77 

31 

17 

4 

243 


Females. 


9 

12 

6 

"2 

30 


Total, 


1 

2 

121 

89 

37 

17 

6 

273 


That  the  entrance  of  cold  salt  water  to  the  ears  is  unpleasant  goes 
without  saying,  and  often  there  is  no  other  effect.  But  inflammation 
of  the  external  auditory  canal  is  a  frequent  result,  and  the  drum-head 
is  yet  more  liable  to  become  inflamed,  because  of  its  greater  delicacy. 
No  serious  inflammation  of  the  latter  ever  takes  place  without  involv- 
ing the  drum  cavity  itself.  The  attic  of  the  tympanum  frequently 
becomes  involved  from  the  entrance  of  water  via  the  Eustachian  tube, 
and  in  some  instances  doubtlessly  the  drum  is  affected  both  from 
without  and  from  within  at  the  same  time.  Where  the  bather's  ears 
contain  an  accumulation  of  cerumen,  this  is  liable  to  saturation  or  dis- 
placement by  the  force  of  entering  water,  and  when  impaction  takes 
place  very  distressing  symptoms  occur. 

The  following  is  a  summary  of  the  aural  diseases  and  complications 
of  existing  diseases  for  which  these  patients  applied  for  treatment: 

Acute  purulent  otitis  media, 69  cases. 

Chronic  purulent  "         "     (from  repeated  exposure  in  bathing),  64  cases. 

Acute  catarrhal  otitis  media, 40  cases. 

Subacute       "          "          " 3  cases. 

Acute  exacerbation  of  existing  chronic  purulent  otitis  media,         .  3  cases. 

Otitis  externa  diffusa, 46  cases. 

Otitis  externa  circumscripta, 5  cases. 

Otitis  externa  exudativa, 2  cases. 

Myringitis  (either  independently  or  in  connection  with  inflamma- 
tion of  the  external  auditory  canal), 30  cases. 

Impaction  of  cerumen, 16  cases. 

Otalgia  due  to  exposure,  etc. ,  .        • 3  cases. 

Aggravation  of  symptoms  arising  from  chronic  catarrhal  inflam- 
mation by  abuse  of  sea  bathing  (bathing  frequently  and  remain- 
ing in  the  water  too  long), 47  cases. 


104  INJTTRT   TO   THE    EAR   FROM   BATHING. 

It  was  noted  that  in  many  of  the  cases  where  injury  to  the  ear  arose 
from  water  being  driven  into  the  meatus  with  great  violence,  injuring 
the  drum-head  and  even  the  walls  of  the  canal  by  mere  force  of 
impact,  the  canals  were  of  larger  calibre  than  ordinary;  in  fifty-seven 
of  the  cases  where  the  size  of  the  canal  was  noted,  they  were  much 
larger  than  normal.  It  is  often  found  that  patients  have  had  repeated 
and  severe  inflammatory  ear  trouble  from  bathing,  before  coming  for 
treatment. 

Fresh-ivater  Bathing. — The  effect  of  fresh-water  bathing  upon  the 
middle  ear  and  surrounding  parts  is  the  same  as  that  of  salt-water 
bathing,  but  in  a  less  degree,  injury  doubtless  occurring  in  a  similar 
way  from  diving  and  sporting  in  the  water.  In  seven  of  the  authors 
cases  of  aural  disease  from  this  source,  four  were  suffering  from  acute 
purulent  inflammation  of  the  drum,  two  from  chronic  purulent,  and 
one  from  chronic  catarrhal  inflammation  of  the  middle  ear.  aggravated 
by  the  bathing. 

Russian  and  Turkish  Baths. — Acute  inflammation  of  the  middle 
ear,  etc.,  is  liable  sometimes  to  occur  after  the  use  of  these  baths, 
which  render  the  patient  extremely  susceptible  to  cold  and  conse- 
quent catarrh  of  the  upper  air  passages.  In  seven  cases  of  persons 
in  the  habit  of  taking  Eussian  baths  coming  under  the  writer's  ob- 
servation, there  was  one  with  acute  purulent  otitis  media,  four  with 
acute  otitis  externa  diffusa,  extending  in  two  patients  to  the  drum- 
head, which  was  also  in  a  state  of  inflammation.  The  drum  was 
also  probably  affected  in  these  cases.  One  patient  finally  was  suf- 
fering from  chronic  catarrh  of  the  middle  ear,  induced  and  ag- 
gravated by  the  habit  of  taking  these  baths  for  a  period  of  many 
years. 

The  author  reports  also  four  cases  of  aural  disease  resulting  from 
long-continued  indulgence  in  the  Turkish  bath.  Two  of  these  patients 
had  chronic  purulent  otitis  media,  and  one  chronic  catarrh  of  the 
middle  ear,  whilst  one  patient  was  suffering  from  acute  inflammation 
of  the  canal. 

Six  cases  of  acute  purulent  inflammation  of  the  middle  ear,  re- 
sulting from  the  effect  of  getting  water  in  the  ears  or  from  the  sus- 
ceptibility induced  by  baths  of  various  kinds,  were  recorded : 

A  shower  bath  in  1  case. 

Hot- water  baths  in  2  cases. 

Hydi'ant  water  falling  in  the  ear  in  1  case. 
Exposure  after  ordinary  bath  in  1  case. 
Bathing  when  overheated  in  1  case. 


ENTRANCE    OF    WATER    INTO    THE    EARS.  106 

One  patient,  a  male  40  years  of  age,  who  was  suffering  from 
chronic  catarrh  of  the  middle  ear,  attributed  a  marked  increase  of 
tinnitus  aurium  to  taking  a  cold  bath. 

The  consequences  of  aural  disease  arising  from  sea  and  other  kinds 
of  bathing  do  not  differ  greatly,  of  course,  from  the  same  affections 
brought  about  by  other  causes.  In  many  instances,  the  course  of 
middle-ear  inflammation  from  bathing  is  attended  by  intense  pain, 
and  a  chronic  discharge  of  an  irremediable  nature  is  often  left  as  a 
legacy. 

ENTRANCE    OF    WATER    INTO    THE   EARS   BY  USE    OF 

THE    NASAL    DOUCHE,    POST-NASAL   SYRINGE, 

SNIFFING  UP  OF  WATER,  ETC. 

That  water  and  other  fluids  may  enter  the  middle  ear  by  way  of  the 
Eustachian  tubes,  causing  often  very  serious  disturbances  of  that 
organ,  is  well  known. 

The  use  of  the  nasal  douche,  now  unfortunately  well  established  in 
domestic  practice,  is  exceedingly  liable  to  injure  the  ears  by  the  trans- 
mission of  the  fluids  used  to  the  drum  cavity.  From  among  the 
numerous  instances  of  this  description  occurring  in  the  practice  of 
the  writer,  the  following  summary  it  is  believed  will  be  of  especial 
interest  here. 

In  eight  cases,  the  prolonged  use  of  the  nasal  douche  caused  aggra- 
vation of  chronic  catarrhal  otitis  media;  in  seven  patients,  chronic 
purulent  inflammation  of  the  middle  ear  remained  as  a  result  of  acute 
processes.  Six  persons  applied  for  treatment  suffering  with  acute 
catarrhal,  and  seven  with  acute  purulent  otitis  media,  induced,  in  all 
cases,  by  the  abuse  of  this  apparatus. 

One  case  of  injury  to  the  ears  from  blowing  spray  through  the  nose 
under  high  pressure  came  under  observation,  and  one  case,  that  of  a 
young  girl  who  was  troubled  with  the  sensation  of  pressure  in  her 
ears  after  using  the  nasal  spray.  This  was  without  doubt  due  to  the 
presence  of  water  forced  into  the  drums.  There  were  four  persons, 
furthermore,  suffering  from  autophonia,  tinnitus,  etc.,  owing  to  the 
employment  of  the  nasal  douche;  one  of  these  patients  employed  a 
cold  solution  of  carbolic  acid,  glycerin,  and  salt. 

Snuffing  water,  or  remedies  in  solution,  up  the  nose  is  not  free  from 
the  same  danger  that  attends  the  use  of  the  above-named  apparatus. 

The  writer  has  observed  a  number  of  such  cases.  Thirteen  persons 
applied  to  him  for  treatment  of  aural  diseases  incurred  from  snuffing 
up  cold  salt  ivoter.     Several  of  these  patients  had  the  habit  of  per- 


106  CLIPPING    AND   WETTING    THE    HAIR    OF    THE    HEAD, 

forming  the  Valsalvan  experiment,  or  blowing  the  nose  violently  after 
the  use  of  this  fluid.  In  nine  of  the  cases,  this  procedure  was  followed 
by  an  attack  of  acute  catarrhal  otitis  media;  in  three  by  acute  puru- 
lent inflammation,  and  in  one  by  chronic  catarrh  of  the  middle  ear. 
Snuffing  up  of  cold  water  produced  aural  disease  in  four  persons;  name- 
ly, in  three,  chronic  catarrhal,  in  one  chronic  purulent  inflammation. 

The  snuffing  up  of  alum  wa^er  induced  catarrhal  inflammation  in  the 
middle  ear  in  two  cases,  with  accompanying  tinnitus  and  increasing- 
deafness;  one  of  these  persons,  in  endeavoring  to  force  the  water  out 
of  his  ear  by  violently  blowing  the  nose,  had  ruptured  the  drum  head. 
Still  another  patient  applied  for  treatment  with  a  bad  attack  of  acute 
purulent  otitis  media  of  both  ears,  caused  by  snuffing  up  of  warm  sea 
water.  The  water  was  felt  to  enter  the  ears  on  several  occasions, 
giving  rise  to  rumbling  noises  and  pain.  The  records  of  the  author 
show,  furthermore,  one  patient  suffering  from  acute  purulent  middle- 
ear  inflammation  caused  by  use  of  the  post-nasal  syringe,  and  two 
cases  of  persons  troubled  with  tinnitus  and  a  "  sensation  of  pressure 
in  the  ears,"  both  of  whom  were  in  the  habit  of  performing  the  Val- 
salvan experiment,  the  water  probably  being  forced  into  the  drums 
by  this  procedure.  One  patient,  furthermore,  was  troubled  with  au- 
tophony,  to  relieve  which  he  had  long  been  in  the  habit  of  sniffing 
up  water  into  the  nose.  In  another  case,  the  existing  aural  disease 
was  seemingly  much  increased  by  the  constant  use  of  snuff. 

In  conclusion,  it  should  be  remarked  that  it  is  not  unlikely  that 
the  mother's  milk,  flowing  freely  into  the  nursling's  mouth,  causing 
strangulation,  is  sometimes  forced  up  along  the  Eustachian  tube  into 
the  tympanic  cavity;  and  this  accident  would  be  still  more  likely  to 
occur  where  the  infant  was  fed  from  a  free-flowing  bottle  while  lying^ 
on  its  back. 

CLIPPING   AND    WETTING    THE   HAIR    OF   THE   HEAD. 

Closely  cropping  of  the  hair  of  the  head,  especially  its  removal 
from  the  parts  immediately  back  of  the  ears,  is  often  seemingly  a 
cause  of  inflammation  of  the  middle  ear.  This  is  obviously  more 
likely  to  occur  among  males  than  females,  the  latter  rarely  having 
the  hair  cut  off. 

Among  eleven  cases  of  this  kind,  where  clipping  the  hair  gave  rise 
to  cold  in  the  head  and  consequent  aural  inflammation,  but  one  pa- 
tient was  a  female,  a  child  of  six  years  of  age.  Three  of  these 
patients  were  suffering,  when  seen,  from  an  attack  of  acute  purulent 
otitis  media;  six  had  acute  catarrhal  inflammation  of  the  middle  ear; 


CLIPPING    AND   WETTING   THE    HAIR   OF   THE    HEAD.  107 

in  one  patient  the  drum-head  was  the  seat  of  inflammation,  in  an- 
other there  was  diffuse  inflammation  of  the  external  auditory  canal. 

The  custom  of  shampooing  or  washing  the  hair  of  the  head  and 
allowing  it  to  dry  slowly  may,  in  a  like  manner,  give  rise  to  ear  trouble. 
Females  with  a  heavy  growth  of  hair  are  especially  liable  to  be 
affected  from  this  cause.  Very  grave  cases  of  purulent  inflammation 
have  resulted  from  these  practices.  Among  six  cases  of  females  with 
aural  troubles  arising  from  such  sources,  there  was  one  case  of  acute 
catarrhal,  three  of  acute  purulent  inflammation  of  the  middle  ear, 
whilst  two  patients  were  suffering  from  acute  exacerbations  of  chronic 
purulent  otitis  media.  One  of  these  persons,  a  girl  of  ten  years,  had 
had  her  hair  cut  a  month  previously,  since  which  time  she  had  the 
habit  of  holding  her  head  daily  under  the  hydrant  "  to  keep  the  hair 
smooth."  Such  cases  are  frequently  met  with,  but  so  universal  is  the 
practice  that  but  few  are  ever  inclined  to  really  estimate  the  risk  in- 
curred thereby. 

One  of  the  most  severe  and  intractable  cases  of  acute  purulent  in- 
flammation that  has  ever  been  seen  by  the  writer  occurred  in  a  lady 
who  exposed  her  head  to  the  cold  air  while  out  driving,  before  the 
hair  had  been  allowed  to  dry  after  being  washed. 


PART    THIRD. 

WOUNDS,  INJUEIES,  AND  DISEASES  OF  THE  EAK,  AND 
THEIR  TREATMENT. 


■   OHAPTEE    IX. 

WOUNDS  AND   INJURIES   OF   THE   EXTERNAL  EAR. 

Cleft  of  Lobule.     Othaematoma.     Gunshot,  Sabre,  and  Arrow  Wounds. 

The  pinna,  or  wing  of  the  ear,  consisting,  as  it  does,  of  a  delicate 
cartilaginous  framework,  occupying  a  prominently  outstanding  posi- 
tion, is  very  much  exposed  to  injuries  from  blows,  delivered  either 
accidentally,  as  in  boxing  or  in  play,  or  from  falls  upon  the  organ. 
Even  lying  upon  a  hard  pillow  may,  especially  under  favorable  con- 
ditions, to  be  alluded  to  further  on,  set  up  inflammatory  action  in  the 
auricle,  the  injury  in  either  case  resulting  from  the  auricle  being 
more  or  less  forcibly  pressed  against  the  head  and  unyielding  tem- 
poral bone.  That  the  auricle  is  not  more  frequently  the  seat  of  dis- 
ease from  these  causes  may  create  some  surprise,  when  it  is  considered 
that  the  perichondrial  envelope  which  everywhere  lies  in  contact  with 
the  cartilaginous  framework  is  so  frequently  liable  to  trauma,  and  its 
consequent  separation  from  the  cartilage  through  inflammatory  effu- 
sion so  often  follows,  as  will  be  seen  under  othcemaioma.  The  exte- 
rior ear  is,  furthermore,  liable  to  gunshot  and  sabre  wounds,  the 
former  occurring  in  warfare  and  also  civil  life,  as  the  result  of  sui- 
cidal attempts  or  accidents.  The  lacerated,  contused,  incised,  and 
punctured  injuries  resulting  especially  from  gunshot  wounds,  may 
affect  the  outer  organ  only,  but  they  very  often  involve  the  middle 
ear  mechanism  or  other  parts  of  the  ear  contained  in  the  tempo- 
ral bone.  Since,  therefore,  all  the  anatomical  parts  of  the  ear  are  ex- 
tremely liable  to  be  included,  their  classification  as  external,  middle, 
or  internal  ear  wounds  or  injuries,  cannot  be  made  conveniently  in 
all  cases. 

CLEFT  OF  LOBULE  (FROM  EARRINGS). 

One  of  the  most  frequent  wounds  of  the  auricle  occurs  in  the  lobe, 
and  is  produced  by  the  fine  wire  of  earrings  gradually  cutting  its  way 
through  the  soft  tissues,  owing  to  the  weight  of  the  pendant,  or  from 


112  OTHiEMATOMA. 

being  torn  out  suddenly.  In  some  cases  the  wire  seems  to  cut  its 
way  through  so  rapidly  as  to  be  followed  by  healing,  a  cicatricial  line 
being  thus  left  in  its  wake.  When  several  parallel  lines  are  thus 
formed,  the  point  of  exit  gives  a  serrated  look  to  the  border  of  the 
lobule.  The  loose  tissue  composing  the  lobule  sometimes  breaks 
down  very  rapidly  under  the  inflammation  excited  by  piercing  and 
the  subsequent  introduction  of  earrings. 

Among  such  cases  coming  under  the  observation  of  the  author,  and 
being  especially  noteworthy  as  occurring  in  sisters,  are  two,  where 
the  same  rings,  both  of  14-carat  gold,  were  used.  In  both  of 
these  children  the  rings  soon  cut  their  way  out,  and  even  a  portion 
of  the  lobule  sloughed  off.  The  accident  could  not  be  altogether  at- 
tributed to  the  base  metal  of  which  the  rings  were  made.  The 
lobules,  in  such  cases  where  these  injuries  are  apt  to  occur,  will  gen- 
erally be  found  very  thin. 

Treatment. — An  operation  for  the  relief  of  the  deformity  when  a 
slit  remains  in  these  cases  is  sometimes  required.  Such  an  operative 
procedure  consists  in  paring  the  edges  of  the  notch  with  a  small 
scalpel,  but  leaving  a  portion  of  the  posterior  paring,  a  few  lines  in 
length,  attached  when  cutting  off  the  slice,  as  suggested  by  Knapp,* 
after  the  Mirault-Langenbeck  operation  for  hare-lip.  This  remain- 
ing fragment,  when  the  raw  edges  of  the  two  sides  have  been  brought 
in  contact  with  each  other,  is  made  to  overlap  and  attach  itself  to  a 
denuded  surface  on  the  opposite  side  of  the  notch,  thus  preventing 
the  occurrence  of  any  gap  on  the  margin  of  the  lobule  after  healing. 

OTHEMATOMA. 

Synonym. — Haematoma  auris ;  Perichondritis  Auriculae. 

Hmmatoma  auris  is  a  disease  of  the  cartilage  and  perichondrium  of 
the  auricle,  with  consequent  formation  of  a  cyst  containing  blood  or 
varying  portions  of  its  constituents. 

The  ancients  were  very  familiar  with  this  morbid  condition  of  the 
auricle,  since  it  was  the  necessary  result  of  boxing-matches,  which 
then  constituted  the  favorite  mode  of  combat.  Among  the  Greeks 
and  Komans  pugilism  was  considered  an  essential  part  of  education, 
as  it  increased  the  strength  and  developed  boldness  of  character  in 
their  youth.  Defence  and  assault  with  the  fist  or  cestus  were  then  ex- 
tremely common,  and  combats  for  amusements  even  were  the  fashion 
of  the  day;  the  Grecian  boxers,  who  were  justly  ^renowned,  had  for 

1  Archives  of  Oph.  and  Otol.,  vol.  iii.,'pp.  254-256. 


OTHEMATOMA.  113 

their  titulary  deity  Pollux  himself.  The  ^neid  abounds  in  praise  of 
these  barbaric  contests  ;  thus  in  the  combat  between  Eutellus  and 
^neas — 

"  A  storm  of  strokes,  well  meant,  with  fury  flies, 
And  errs  about  their  temples,  ears,  and  eyes  — 
Nor  always  errs,  for  oft  the  gauntlet  di'aws 
A  sweepmg  sti'oke  along  the  crackling  jaws." 

The  implement  employed  by  the  classic  slugger  in  these  auricle-crack- 
ing feats  was  the  cestus,  a  formidable  gauntlet  composed  of  thongs  of 
several  thicknesses  of  raw  hide  strongly  fastened  together  and  loaded 
with  lead,  iron,  or  brass,  and  bound  to  the  arm  by  thongs.  Four 
varieties  of  this  crushing  implement  are  known  to  have  been  in  use, 
the  least  deadly  being  more  dangerous  even  than  the  modern  assassin's 
"brass  knuckles,"  and  capable  of  administering  a  fatal  blow.  These 
murderous  weapons  were  known  to  Virgil  as  the  "gloves  of  death.'' 
Pauhis  JEgenita  refers  to  the  aural  injuries  produced  by  this  weapon 
as  contusions  of  the  ear,  and  Hippocrates  described  them  as  fractures 
of  the  auricle,  adding  that  the  injury  was  a  common  one  in  his  day. 
"  The  combat  with  the  cestus,"  he  says,  "was  a  favorite  amusement 
of  the  ancients,  and  a  blow  about  the  ears  was  reckoned  a  master- 
stroke, sometimes  being  fatal."  At  a  later  date  the  amphotides,  a 
helmet  or  headguard,  was  worn  to  protect  the  temporal  bones,  arteries, 
and  ears.  It  was  constructed  with  thongs  and  ligatures  made  of  the 
hides  of  bulls,  studded  with  knobs  of  iron,  and  thickly  quilted  inside 
to  dull  the  concussion  of  blows.  The  pugilists  and  the  pancratiastes, 
armed  with  the  cestus,  were  in  the  habit  of  producing  such  disfigure- 
ment of  the  ears  that  it  became  a  customary  plastic  ornament  in  an- 
tique sculpture,  which  thus  affords  abundant  evidence  of  the  results 
of  these  practices ;  for  example,  the  heads  of  Hercules,  PoUus,  Hec- 
tor, and  other  warriors  have  been  represented  with  ears  having  this 
typical  deformity  of  ancient  contestants.* 

The  ancient  custom  of  boxing  has  been  continued  by  the  Anglo- 
Saxon  race,  especially  in  Great  Britain,  where  for  a  long  time  past  it 
has  been  encouraged  as  a  national  amusement  and  has  a  literature  of 
its  own.  During  this  period  of  time,  however,  the  unprotected  fist 
has  been  employed  in  combat,  and  the  occurrence  of  the  more  serious 
aural  injuries  has  in  consequence  diminished.  Pugilism  has  now 
everywhere  fallen  into  disrepute,  and  its  votaries  are  principally  con- 
fined to  low  resorts,  where  the  boxers  enter  the  lists  with  gloved  fists 

'  Vide  Gudden  :  Haematic  Swelling  of  the  Ears  of  the  Insane.    AUg.  Zeit.. 
flir  Psychiatrie,  Bd.  xvii.    Med.  Critic,  January,  1861.     Banking's  Abst.,  vol.. 
1.,  p.  43,  1861. 
8 


114  OTHEMATOMA. 

and  go  through  the  forms  of  a  ''  mill  "  for  the  amusement  of  the  au- 
dience. Even  here,  however,  we  find  that  some  vigorous  blows  about 
the  head  are  demanded,  and  the  ear  is  frequently  struck,  especially 
in  "  cross  counter,"  in  which  the  left  ear  suffers  most.  The  frequent 
pounding  of  the  left  auricle  in  this  manner  often  gives  rise  to  othae- 
matoma.  A  very  considerable  number  of  persons  are  at  present  en- 
gaged in  this  occupation  for  a  livelihood,  and  most  of  them  have 
characteristically  deformed  auricles. 

The  tendency  to  violent  contests  has  shown  itself  in  other  pastimes 
where  the  ear  does  not  always  escape  injury  ;  thus  Farquharson'  de- 
scribes several  cases  of  the  disease  under  consideration,  coming  on 
suddenly,  with  oval  swelling  of  the  auricle,  as  a  consequence  of  play- 
ing the  game  of  foot-ball  at  Rugby,  where  there  is  much  forcible  but- 
ting with  the  head  in  "tight  scrimmage." 

Etiology. — Of  purely  traumatic  othaematoma  no  mention  need 
be  made  here,  but  in  regard  to  the  origion  of  the  so-called' 
idiopathic  or  spontaneous  variety  there  has  been  much  difference 
of  opinion.  The  first  description  of  othaematoma,  in  which  mental 
-and  other  nervous  disturbances  play  so  important  a  part,  was  pub- 
lished fifty  years  ago  by  Dr.  Friedrich  Bird,''  then  connected  with 
the  asylum  at  Sieburg.  Bird  gave  a  very  good  account  of  six  cases 
coming  under  his  observation,  and  drew  attention  to  the  intimate  re- 
lations of  the  disease  to  insanity.  He  was,  however,  at  a  loss  to  ac- 
count for  its  origin,  having  never  traced  it  to  outward  injury,  but  in 
five  of  his  cases  it  is  noted  that  there  was  active  congestion  of  the 
head.  The  suggestions  thrown  out  by  Bird  finally  received  the  atten- 
tion of  other  writers  :  M.  Ferris,  a  Frenchman,  gave  the  subject  his 
attention  in  1838,  and  ten  years  later  (1848)  the  valuable  essay  on  the 
subject  by  Franz  Fischer''  was  written.  The  observations  of  alienists 
were  naturally  limited  to  the  occurrence  of  the  disease  in  insane  per- 
sons ;  in  1852,  however,  an  Englishman,  Mr.  S.  Ozier  Ward,  drew 
attention  to  the  liability  of  the  mentally  sane  to  the  trouble.* 

Numerous  contributions  have  been  made  to  the  literature  of  the 
subject  during  the  past  thirty  years.     In  1858  an  interesting  paper 

» British  Medical  Journal,  Vol.  ii.,  p.  59,  1873, 

'^  Upon  a  Curious  Sort  of  Inflammation  of  the  Outer  Ear  Occurring  in  Insane 
Patients.  Friedrich  Bird.  Graefe's  and  Walther's  Journal,  B.  19,  p.  361.  See 
Aba.  M.  Ch.  Rev.,  Vol.  xxiv.,  p.  201,  1834. 

■*  Die  Ohrblutgeschwulst  der  Seelengestorten,  nebst  einer  Beobachtuug  der 
Kopfblutgeschwulst  bei  einem  solchen  Kranken.  Allg.  Ztschr.  f.  Psychiat., 
etc.,  Berl.,  1848,  v.  i.  Also  Dr.  Arlidge's  translation,  Asylum  Journal.  1854, 
pp.  45-107. 

*  Medical  Times  and  Gazette,  Vol.  ii.,  p.  295,  1852. 


OTHEMATOMA.  115 

was  published  by  Stiff,  ''On  Simple  Sanguineous  Cyst  of  the  Ear  in 
Lunatics,"  '  and  in  1859  the  distinguished  labors  of  M.  A.  Foville 
were  made  known.' 

It  will  be  found  on  consulting  the  "  Index  Catalogue  of  the  Library 
of  the  Surgeon- General's  Office"^  that,  although  incomplete  as  yet 
ia  respect  to  this  subject,  fifteen  monographs  and  forty-six  journal 
articles  and  other  papers  pertaining  to  othgematoma  were  published 
between  the  years  1848  and  1879  by  German,  English,  Italian  and 
American  authors. 

One  cannot  witness  the  intense  congestion  of  the  ears,  sometimes 
accompanying  great  cerebral  excitement  in  the  insane,  without  belief 
in  the  possibility  of  spontaneous  extravasation  of  blood  taking  place  be- 
neath the  perichondrium;  and  it  would  seem  possible  that  where  tissue 
changes,  to  be  immediately  referred  to,  have  already  taken  place  in 
the  cartilage  and  perichondrium,  othaematoma  may  sometimes  thus 
occur.  These  nutritive  changes  in  the  auricle,  believed  to  pave  the 
way  for  extravasation,  so  to  speak,  will  first  demand  our  attention. 
The}'  seem  to  be  mainly  brought  about  through  the  agency  of  the 
nervous  system,  although  some  authorities  lay  much  stress  on  the  in- 
fluence of  blood  dyscrasias  in  producing  changes  in  the  blood-vessels 
of  the  part.  The  weight  of  evidence,  however,  leads  to  the  conclu- 
sion that  they  most  frequently  depend  on  a  morbid  state  of  the  brain, 
especially  on  congestion  of  the  organ.  Functional  disturbance  of  the 
brain,  or  of  the  cerebro-spinal  centre,  giving  rise  to  disorder  of  the 
cervical  sympathetic,  may,  by  reason  of  the  dominance  thus  exercised 
on  the  vessel  regulating  nerves  distributed  to  both  intercranial  ganglia 
and  the  auricle,  set  up  hyperaemia  in  the  former,  and  vascular  changes 
in  the  latter.*  Wiien  othaematoma  occurs  in  the  course  of  genera 
paralysis,  it  would  seem  that  aural  congestion  took  place  in  conse- 
quence of  general  degeneration  of  the  sympathetic;  and  it  has  been 
suggested  that  in  inflammation  of  the  brain  the  aural  disease  becomes 
advantageous  to  the  patient,  since  the  hemorrhage  is  tlius  spent  upon 
the  posterior  auriculars,  coming  from  the  middle  meningeal.' 

'  B.  and  F.  Med.  Chir.  Rev.,  Vol.  xxi.,  pp.  169-174.     Am.  Ed.,  1858. 

-  Recherches  sur  les  tumeurs  sanguines  du  pavilion  de  I'oreille  chez 
alienes.  Ann.  Med. -psych.,  Par.,  1859,  3.  S.,  v.,  390-408.  Also:  Gaz.  hebd. 
de  nied.,  Par.,  1859,  vi.,  450,  469.  Also  ;  transl.  Am.  J.  Insan.,  Utica,  N.  Y., 
1859-60,  xvi.,  184-200.  Vide  also,  Hematorae  du  pavilion  de  roreille  chez  un 
aliene.     Union  med.  de  la  Seine-inf.,  Rouen,  1877,  xvi.,  24,  37. 

^  Vol.  i..  Government  Printing  Office,  Washington,  1880. 

*Vide  Robertson,  Glasgow  M.  J.,  vol.  vii.,  July,  1875. 

»  Bonnet:  Annales  Medico-Psychologiques,  1877.     A.  J.  O.,  vol.  i.,  p.  68. 


116 


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11 

OTHEMATOMA.  119 

But  while  central  morbid  conditions  are  justly  regarded  as  of  great- 
est importance,  other  impressions,  propagated  by  morbid  processes  in 
other  organs  through  the  sympathetic  system,  are  worthy  of  consid- 
eration; thus,  in  the  examination  of  insane  subjects  having  this 
affection,  the  almost  universal  prevalence  of  nasal  catarrhs,  diseased 
teeth,  and,  in  the  female,  of  uterine  disease,  is  notable,  and  it  is  well 
known  that  the  irritation  due  to  these  influences  is  transmitted 
through  the  nerves,  and  may  not  only  exasperate  cerebral  disease 
itself,  but  is  liable  to  also  affect  the  organ  of  hearing. 

The  predisponenfs  believed  to  have  an  important  relation  to  othae- 
matoma  require  consideration  somewhat  in  detail. 

1.  Age. — Othaematoma  is  generally  found  in  adults,  although  a 
number  of  cases  occurring  in  children  have  been  observed  and  re- 
ported by  various  writers.  Langenbeck  reports  a  case  occurring  in  a 
girl,  twelve  years  of  age,  who  was  said  to  be  tvild.  Blau'  describes  a 
case  observed  in  a  gymnast,  aged  fifteen  years,  where  there  was  no 
ps3'^cho-  nor  neuropathic  family  history.  The  case  had,  it  is  said,  no 
history  of  trauma,  but  it  is  significant  that  otorrhoea  existed. 
Schwartze  has  seen  a  case  in  a  child  fourteen  years  of  age,  and  Julius 
Erhard  '^  speaks  of  cases  arising  in  nurslings  from  rough  handling  or 
injury,  causes  from  which  the  writer  has  never  seen  the  affection 
arise.  If  the  disease  ever  exists  in  very  young  children,  its  occurrence 
seems  to  be  quite  exceptional. 

A  case  of  othaematoma  occurring  a  female  child,  aged  two  years, 
was  reported  by  Wiener,^  and  which  was  considered  by  that  author  to 
be  spontaneous  in  its  origin;  no  history  of  trauma  could  be  discovered. 

In  regard  to  the  appearance  of  othaematoma  in  the  insane,  it  may 
be  said  that  insanity  is  not  obnoxious  to  youth,  nor  is  degeneration  of 
the  cartilage  liable  to  occur  at  this  early  age. 

Contusion  of  the  auricle  may,  of  course,  occur  at  any  age.  The 
disease  has  not  been,  to  the  writer's  knowledge,  ever  reported  in 
extreme  old  age,  which  would  seem  to  confirm  the  view  that  degen- 
eration in  structure  alone  is  not  a  sufficient  cause,  but  that  its  occur- 
rence must  be  looked  for  in  the  active  period  between  adolescence 
and  the  decline  of  life. 

2.  Sex. — Writers  are  generally  in  accord  respecting  the  greater  fre- 
quency of  othaematoma  in  the  male.     Mr.  Nicol,*  who  examined  the 

1  Arch.  f.  Ohrenheilk.,  B.  xix.,  Hft.  4,  pp.  203,  204. 
■^  Vortrage  uber  die  Krankheiten  des  Ohres,  p.  132.     Leipzig,  1875. 
^  Richmond  and  Louisville  Med.  Journal,  vol.  xxii.,  p.  16. 
*  Othaematoma,  or  the  Asylum  Ear.     B.  and  F.  Med.  Chir.  Rev.,  No.  xci., 
July,  1870. 


120  OTH>«MATOMA.  x 

ears  of  a  considerable  number  of  the  inmates  of  the  Sussex  Asylum, 
found  in  24  of  them  more  or  less  deformity  of  the  auricle,  in  several 
of  them  the  disease  being  in  progress.  Of  the  700  patients  in  the 
institution,  2  women  only  were  affected.  Of  the  ^49  asylum  patients 
examined  by  Stiff,  viz.,  124  men  and  125  women,  he  found  the  carti- 
lage of  the  ear  more  or  less  thickened  in  17,  probably  the  results  of 
othematoma;  of  these,  12  were  males  and  5  were  females.  In  the  six 
cases  reported  by  Dr.  Bird,'  all  of  them  were  females. 

Lennox  Browne^  examined  1,424  cases  in  the  West  Eiding  Asylum, 
707  of  whom  were  males,  and  717  were  females.  He  found  that  of 
the  32  patients  affected,  24  were  males  and  8  were  females,  making 
3.39  per  cent  of  the  males  and  1.11  per  cent  of  the  females  affected — 
an  average  of  2.24  per  cent.  M.  Foville,  in  alluding  to  this  subject, 
says  the  affection  occurs  most  frequently  in  males.  Hun '  reports  24 
cases  of  the  disease,  23  of  them  being  males  and  1  of  them  a  female. 
The  writer  himself  found  in  the  statistics  kindly  furnished  him  by 
the  Blackwell's  and  Ward's  Island  Institutions  for  the  Insane  (see 
tables  I.  and  II.),  that  among  1,309  females,  16  cases  of  othsematoma 
were  found,  while  in  1,296  males,  14  cases  were  found,  this  inclusive 
of  ears  previously  affected,  as  shown  by  deformity  of  the  auricle,  and 
those  in  progress  at  the  time  the  examinations  were  made. 

This  shows  a  percentage  of  1.14  in  females,  and  1.10  in  males.  It 
will  thus  be  seen  that  the  greater  number  of  cases  occurred  among 
females.  The  writer,  however,  would  refer  here  to  the  table  (page 
151)  of  9  cases  observed  by  him,  occurring  in  mentally  sane  persons. 
It  will  be  seen  tliat  of  this  number,  but  one  was  a  female.  In  the 
opinion  of  some  alienists  female  lunatics  are  more  violent  than  males, 
and  the  observations  of  Dr.  Bucke,  of  the  Asylum  at  London, 
Canada,  would  seem  to  verify  such  a  belief.  In  a  recent  report,  in 
referring  to  the  restraint  required  in  an  average  population  of  372 
men  and  394  women,  he  says  that  25  men  were  restrained  and 
secluded  4,079  hours,  and  68  women  20,324  hours.  The  reporter 
offers  no  explanation  for  this,  but  states  that,  on  the  whole,  females 
are  more  unmanageable  than  males. 

Women  are  said  to  enjoy  considerable  immunity  from  the  general 
paralysis  of  the  insane,  and  consequently  to  escape  the  frequent  par- 
oxysms of  excitement  which  characterize  this  phase  of  mental  disease. 
On  the  other  hand,  women  are  subject  to  a  monthly  aggravation  of 

'  Op.  cit. 

^  Oth?ematoma,  or  the  Insane  Ear.     West  Riding  Lunatic  Asylum  Reports, 
Vol.  v.,  p.  149,  1875. 
^Hsematoma  Auris.    A.  J.  I.,  July,  1870.     Reprint. 


OTHEMATOMA.  121 

symptoms  during  the  menstrual  period,  since  the  mentally  sane  even 
are  more  irascible  anc^  nervous  at  this  time. 

.The  treatment  of  female  lunatics,  moreover,  is  more  gentle  than 
that  of  males,  since  their  attendants  are  usually  of  their  own  sex,  and 
less  liable  than  male  nurses  to  injure  the  ear  in  handling  violent  and 
idiotic  patients.  The  ears  of  a  female  are  somewhat  protected  by 
their  hair  and  head-dressings. 

3.  Cachexia. — A  dyscrasia  commonly  attends  cerebral  disturbances 
in  both  insane  and  intemperate  persons,  and  although  othsematoma  by 
no  means  always  appears  in  subjects  when  the  bodily  health  is  most 
impaired,  yet  must  we  not  entirely  ignore  a  perversion  of  general 
nutrition,  since  this  state  may  be  in  some  degree  predisposing.  The 
scorbutic  or  rheumic  diathesis,  or  chronic  alcoholism  may  thus  tend 
to  impair  the  texture  of  the  coats,  when  laceration  of  the  blood-ves- 
sels of  the  cartilage  and  perichondrium  would  more  readily  take  place 
in  passive  hemorrhages  occurring  under  undue  excitement.  Thus  Dr. 
Wallis,'  superintending  physician  of  the  Insane  Asylum  at  New 
Euppen,  assumes  a  cachectic  condition  in  conjunction  with  trauma  as 
composing  the  etiological  factors  in  otha^matoma. 

Causative  [traumatic)  agencies.— In  the  mentally  sane  the  affection 
is  most  commonly  met  with  among  prize-fighters,  gymnasts,  persons 
given  to  violent  sports,  and  among  drunken  and  disorderly  persons, 
where  blows  and  falls  are  frequent. 

As  regards  the  insane  there  has  existed  much  diversity  among 
writers  as  to  the  cause.  M.  Bouteille,  who  does  not  absolutely  reject 
the  influence  of  predisposing  causes,  believes  that  othsematoma  never 
appears  without  violence  to  the  auricle,  and,  in  alluding  to  an  epi- 
demic of  othaematoma  which  occurred  at  Lyons  in  1879,  states  that  the 
trouble  disappeared  by  simply  changing  attendants.'^  But  it  is  be- 
lieved that  the  ear  is  now  less  frequently  injured  by  violence  than 
formerly,  since  mechanical  restraints  are  less  in  vogue,  and  an  ameli- 
oration in  the  general  management  of  the  insane  has  gradually  taken 
place.  Not  long  ago  it  was  not  unusual  for  attendants  to  lead  resist- 
ing patients  by  the  ear,  and  otherwise  maltreat  the  organ. 

In  some  of  the  institutions  for  the  insane  where  the  writer  has 
made  inquiries  concerning  the  prevalence  of  othaematoma,  it  would 
seem  to  be  of  infrequent  occurrence;  in  one  asylum  a  case  had  not 
been  observed  in  "  three  or  four  years,"  and  in  respect  to  this  matter 

1  Med.  Zeitung,  heiausgegeben  von  dem  Verein  fur  Heilkundein  Preussen, 
1844.     No.  32,  p.  147.     Ibid.,  1845,  No.  45.  p.  311. 

*  Annales  Medico-Psycliologiques,  Juillet,  1878.  Abst.  A.  J,  O.,  vol.  i.,  p.  69. 


122  OTHEMATOMA. 

in  another  institution  the  superintendent  writes  that  the  case  books 
show  that  the  "phenomenon  has  been  regarded  as  a  curious  incident 
worthy  of  mention,  but  without  sufficient  importance  in  the  history 
of  the  insane  individual  to  merit  description." 

From  a  careful  study  of  the  subject  the  author  has  come  to  believe 
that  othaematoma  is  almost  always  due  to  violence  inflicted  upon  the 
auricle.  Asylum  superintendents,  however,  have  been  on  the  whole, 
perhaps,  rather  disposed  to  undervalue  the  importance  of  mechanical 
causes,  since  it  might  be  constructed  to  imply  undue  restraint  or 
rudeness  in  the  management  of  their  patients. 

It  is  true  that  the  trouble  does  not  always  supervene  during 
paroxysms  of  violence,  but  it  is  difficult  or  impossible  even  to  trace 
physical  injury  in  all  cases,  or  to  show  per  contra  that  the  violent 
patients  have  not  injured  themselves.  Lunatics  themselves  injure 
their  ears  by  self-inflicted  blows.  The  extent  to  which  this  is  carried 
by  these  unfortunate  people,  whose  ears  are,  as  a  matter  of  fact, 
much  le:JS  sensitive  than  normal,  is  much  greater  than  would  seem 
possible  to  any  one  unfamiliar  with  their  habits.  It  is  not  un- 
common for  any  one  to  strike  with  the  fist  upon  a  region  of  the 
body  where  a  morbid  process  gives  rise  to  slight  pain,  and  even  sane 
persons  pull  and  rub  the  auricle  violently  under  certain  conditions. 
The  insane  carry  this  much  farther,  especially  when  under  excitement. 
One  should  not  lose  sight  of  the  fact  that  the  insane  are  liable  to  ex- 
perience much  discomfort  in  the  ears  from  diseases  of  the  organ,  to 
many  of  which  they  are  particularly  subject,  but  delusions  and  hal- 
lucinations are  frequently  so  associated  with  tinnitus  aurium  and 
autophonia  that  the  patient's  attention  is  continually  drawn  to  the 
ear.  They  have  delusions  respecting  the  presence  of  persons  and 
things  in  the  head,  and  concerning  fancied  attempts  of  "  evil  spirits  " 
to  gain  admission  thereto;  they  are  in  constant  dread  when  awake, 
because  of  the  abusive  and  threatening  language  which  they  imagine 
to  be  spoken  into  the  ears.  Frequently  the  patient's  words  become 
autophonous  when  the  ears  and  head  seem  "  empty  "  or  "  cavernous  "; 
it  then  becomes  yet  more  difficult  for  the  patient  to  not  imagine  or 
believe  that  abominable  and  dangerous  occupants  have  taken  posses- 
sion of  the  disordered  and  void  dormitory  of  the  mind.  Autophonia, 
which  is  an  expression  intended  here  to  embrace  the  various  forms 
of  tinnitus  as  well  as  autophonous  vocal  and  respiratory  sounds,  gives 
rise  to  hallucinations  in  mentally  sane  subjects  even,  especially  in  the 
aged  and  feeble. 

Worthy  of  mention  in  this  connection  is  the  distressing  itching 
and  burning  sometimes  set  up  in  the  ear  in  neurotic  subjects,  relief 


OTHEMATOMA.  123 

from  which  is  sought  by  constantly  pulling,  pounding,  rubbing,  and 
pinching  the  external  parts.  The  writer  has  known  sane  persons  to 
endeavor  to  get  some  relief  from  the  torture  of  pruritus  of  the  ear 
by  treating  the  organ  with  much  violence  ;  a  lady  under  his  care  at 
the  one  time  often  found  herself  involuntarily  scratching  the  auricle 
and  temple  on  account  of  "  creeping  sensations "  in  the  ear,  and 
another  patient,  a  clergyman,  had  the  habit  of  thrusting  a  large  pin 
deep  down  into  the  external  auditory  canal  to  scratch  the  parts  ;  he 
also  rubbed  the  auricle  at  times  until  it  became  intensely  injected. 

Lunatics  often  thrust  objects  like  wool,  rags,  etc.,  into  the  ex- 
ternal auditory  canal  to  get  rid  of  disagreeable  noises  in  the  ears  and 
head.  The  organ  is  frequently  injured  in  this  way  ;  the  author  has, 
for  example,  seen  a  case  where  much  damage  was  inflicted  by 
thrusting  the  rough  end  of  a  china  dolFs  leg  into  the  ear,  and  in 
another  instance,  a  large  abscess  was  produced  on  the  inner  surface 
of  the  auricle  by  rubbing  and  contusing  it  with  a  stone.  In  some 
instances,  the  insane  strike  the  head  against  some  object  with  great 
violence,  the  injuries  thus  produced  leaving  the  auricles  abraded  and 
scratched  ;  others  thrust  tlieir  forefingers  into  the  ears  and  furiously 
shake  and  pull  the  organs— in  one  case  seen  a  papillary  growth  had 
developed  at  the  entrance  of  the  external  auditory  canal  on  one  side 
in  consequence,  and  both  auricles  were  greatly  enlarged. 

It  will  thus  be  seen  that  insane  persons  very  frequently  have 
a  fancy  that  the  organ  of  hearing  constitutes  the  portal  of  the 
mind,  and  we  need  not  wonder,  therefore,  that  it  is  so  frequently  as- 
sailed. 

Among  other  numerous  causes  may  also  be  enumerated  the  violent 
movements  of  certain  insane  persons  when  in  bed  ;  their  pillows, 
frequently  consisting  of  materials  no  softer  than  straw  or  husks,  are 
liable  to  injure  their  ears,  esjiecially  during  their  struggles  under 
restraint.  Again,  when  forcibly  fed,  while  the  head  is  held  in  the 
strong  embrace  of  the  nurse,  the  ears  are  liable  to  injury.  Insane 
paralytics,  if  allowed  to  remain  too  long  without  change  in  position, 
may  suffer  from  an  interference  in  the  process  of  nutrition  on  account 
of  the  undue  pressure  upon  the  ear.  Sloughing  of  the  auricle  from 
long-continued  pressure  in  lying  upon  the  organ  in  cases  of  fever  not 
unfrequently  occurs  in  the  mentally  sane.* 

Othaematoma  has  been  described  by  writers  on  the  ear  as  due  to 
bites,  burns,  dentition,  etc.     Urbantschitsch*  reports  the  case  of  a 

J  Williams'  Treatise  on  the  Ear,  p.  103.    London,  1840. 
» Lehrbuch,  p.  89. 


124  OTH.EMATOMA. 

woman  where  both  ears  were  believed  to  be  thus  affected  by  a  bite  of 
some  kiud,  and  Kipp'  reports  the  case  of  a  child,  considered  to  be 
thus  affected,  where  both  auricles  were  injured  by  a  burn.  Cases 
supposed  to  be  due  to  dentition  are  related  by  Frank/  who  says: 
*' During  dentition,  this  condition  is  often  observed  to  occur,  usually 
in  scrofulous  subjects."  The  writer,  whose  experience  in  this 
disease  has  been  considerable,  has  never  seen  othaematoma  arise 
from  any  of  these  causes,  and  it  seems  probable  that  in  some  of 
them  at  least  phlegmonous  inflammation  only  may  have  been 
present. 

In  reviewing  the  causes  of  othaematoma,  it  would  seem  that  it 
has  no  special  preference  for  either  sex  or  for  any  one  form  of 
insanity,  and  that  it  may  be  produced  in  the  mentally  sane  by 
contusion  of  the  auricle.  That  it  depends  almost  exclusively 
upon  traumatic  influences  in  all  cases  seems  a  warrantable  deduc- 
tion. 

From  the  examination  in  his  own  practice  of  a  very  considerable 
number  of  cases  of  othaematoma  occurring  in  both  mentally  sane  and 
insane  subjects,  and  consisting  of  cases  in  progress  as  well  as  where 
recovery  had  taken  place, .the  writer  entertains  no  doubt  in  his  own 
mind  as  to  the  universal  and  immediate  precedence  of  trauma  in  every 
install  ce. 

Occurrence, — The  more  frequent  occurrence  of  othaematoma  in  the 
left  ear  has  been  the  subject  of  much  speculation.  Stiff '  drew  at- 
tention to  this  preference;  he  found  that  in  17  cases  the  left  ear  was 
affected  in  6  cnses,  the  right  ear  in  4,  and  both  ears  in  7.  Of  the  24 
cases  reported  by  Lennox  Browne,  the  left  ear  was  affected  in  19,  the 
right  ear  in  2,  and  both  ears  in  11;  when  both  ears  were  affected  the 
left  was  first  attacked.  The  experience  of  some  observers  has  been 
the  reverse  of  the  authorities  above  quoted;  thus  Hun,*  in  his  24 
cases  found  the  right  ear  to  be  the  seat  of  the  trouble  in  9  cases,  the 
left  in  5,  both  ears  in  9,  and  in  one  the  history  was  incomplete  in  this 
regard.  In  the  cases  where  both  ears  were  affected  it  is  not  stated 
which  side  was  first  attacked. 

The  greater  frequency  of  occurrence  in  the  left  ear  does  not  seem 
to  hold  good  in  the  mentally  sane  (see  table  of  the  author^s  cases,  p. 
151),  with  the  exception  of  pugilists,  who  more  frequently  contuse 
the  left  auricle. 

'  Trans.  A.  O.  Soc,  1867,  p.  79. 
*  Ohrenkrankheiten,  p.  248. 
'Loc.  cit. 
*LiOc.  cit. 


OTH.EMAT0MA.  125 

Various  theories  have  been  advanced  in  explanation  of  this  peculiar 
manifestation.  Thus  it  has  been  suggested  that  the  near  position 
of  the  left  carotid  artery  to  the  heart  affords  a  more  direct  blood 
supply  to  the  left  ear,  and  that,  furthermore,  the  left  pinna  is  often- 
est  affected,  because  pulling  or  striking  the  organ  is  more  liable 
to  be  done  with  the  right  hand,  the  left  ear  receiving  the  injury. 
The  left  ear,  it  is  said,  is  also  more  liable  to  injury  than  the 
right  in  forcible  feeding,  since  in  holding  the  patient  the  arm  of 
the  nurse  usually  presses  it  with  more  or  less  violence  against  the 
head.* 

An  explanation  of  the  greater  frequency  of  left-sided  othsematoma, 
however,  must  be  sought  in  some  other  direction,  sipce  the  above- 
apply  mainly  to  mechanical  agencies  only.  It  seems  probable  that 
some  very  intransient  influence  must  exist  to  cause  the  trouble  to  ap- 
pear so  frequently  on  the  left  side,  and  could  this  be  discovered, 
much  light  would  doubtlessly  be  thrown  not  only  on  the  etiology  of 
othaematoma,  but  also  on  other  aural  diseases.  It  has  occurred  to  the 
writer  that  probably  some  vaso-motor  influence  might  be  found  to 
lie  at  the  bottom  of  the  difficulty.  It  is  a  fact  that  unilateral 
sweating  about  the  head  is  not  an  uncommon  occurrence ;  and, 
moreover,  in  bilateral  chronic  catarrh  the  left  ear  is  seemingly  much 
more  rapidly  invaded  than  the  right  in  a  notable  number  of  instances. 
— a  condition  due,  in  all  probability,  to  some  vaso-motor  disturbance^ 
whereby  the  nutritive  process  is  interfered  with  much  more  on  the 
left  than  on  the  right  side.  While  this  agency  may  be  found  to  lie 
in  some  cerebral  or  cerebro- spinal  condition,  there  exists  a  prominent 
irregularity  in  the  distribution  of  the  sympathetic  nerves  which  it 
occurs  to  the  writer  might  bring  about  such  a  result.  Reference  is- 
had  to  the  peculiar  arrangement  of  the  nerves  extending  upward 
from  the  cardiac  plexus  to  the  two  sides  of  the  head.  According  to 
anatomists  there  is  to  be  found  here  an  important  irregularity. 
Thus,  while  an  unvarying  connection  is  maintained  with  the  right 
side  through  the  superior  cervical  ganglion,  a  comparatively  im- 
perfect and  varying  connection  exists  on  the  left  side — the  left  su- 
perior cardiac  nerve  and  the  inferior  cardiac  branch  of  the  pneumo- 
gastric  only  occasionally  affording  communication  between  the  cardiac 
plexus  and  the  left  superior  cervical  ganglion. 

Of  course,  other  but  less  direct  communications  exist,  which  bring 
the  cardiac  plexus  into  relationship  with  the  left  ear,  nevertheless 
the  asymmetrical  distribution  above  described  might  be  the  means  of 

'  The  writer's  attention  was  drawn  to  this  latter  explanation  by  Dr.  Craig,. 
Assistant  Surgeon,  New  York  Asylum  for  the  Insane. 


126  OTH-CMATOMA. 

diminishing  the  vaso-motor  dominance,  in  respect  to  the  circulation 
in  the  left  ear.  Granting  the  correctness  of  the  hypothesis,  which, 
however,  is  by  no  means  held  to  be  indisputable,  the  disparity  in  the 
vascularity  of  the  two  ears  would  finally  produce  distinguishing 
nutritive  changes  in  the  tissues  of  the  parts— alterations  especially 
well  marked  in  the  tympanic  membranes  in  otitis  media  catarrhalis 
chronica,  where  the  membrane  of  the  left  tympanum  will  frequently 
be  found  to  be  quite  parchment-like  and  lustreless,  while  the  right 
membrane  is  yet  in  a  fairly  normal  condition.  It  is  thus  difficult  to 
see  why  nutritive  changes  may  not  affect  the  cartilage  of  the  left  ear 
more  frequently  than  the  right,  and  give  rise  to  the  greater  frequency 
of  othaematoma  on  the  left  side. 

Othaematoma  is  frequently  bilateral,  very  often  developing  equally 
on  both  sides.  It  may  develop  rapidly  and  disappear  again  as  rapidly 
as  it  came.  This  bilateral  invasion  is  suggestive  of  central  nervous 
origin. 

Pathology. — After  what  has  been  previously  stated  in  respect  to 
this  affection,  there  remains  but  little  to  be  said  concerning  its  path- 
ology. There  seems  to  be  but  little  doubt  of  the  existence  in  many 
lunatics  and  inebriates  of  incipient  softening  and  disintegration  in 
the  tissues  of  the  auricle,  which  predispose  to  separation  of  the  peri- 
chondrium from  the  cartilage;  that  this  is  always  a  factor  of  very 
great  importance  in  the  production  of  othaematoma  may  well  be 
doubted,  since  the  disease  is  scarcely  ever  known  to  occur  in  advanced 
life,  when  such  changes  would  be  greatest,  unless  mechanical  agen- 
cies intervene.  The  extent  to  which  softening  of  the  cartilage  may 
proceed  without  any  symptoms  manifesting  themselves  is  not,  of 
course,  known,  but  from  the  following  extract  it  is  probably  very 
considerable.  Referring  to  the  pathological  histology  of  the  carti- 
laginous framework  of  the  ear,'  Pollak  shows  that  specimens  "  which 
were  taken  from  the  ears  of  individuals  who  had  not,  so  far  as  he 
could  learn,  been  affected  with  any  form  of  mental  disease,"  had  *'  in 
the  cartilaginous  portion  of  the  external  meatus,  and  especially  in  the 
antihelix,  small  nodules"  varying  in  size  ''from  a  mustard-seed  to  a 
lentil."  These,  when  cut  open,  showed  to  the  naked  eye  even  a  de- 
parture from  the  normal  condition  of  the  reticulated  cartilage,  and 
sections  under  the  microscope  were  found  to  be  deprived  of  the  fibril- 
lated  network  in  places,  and  instead  there  was  a  structureless  mass. 
In  some  places  the  breaking-down  process  was  even  more  marked. 

'  Monatschrift  fflr  Ohrenheilkunde,  July,  1879— Rev.  in  A.  J.  O.,  vol.  i.,  pp. 
80S,  303. 


OTHEMATOMA.  127 

Where  an  actual  cavity  was  made  out,  it  "lay  wholly  within  the  mass 
of  cartilage,  and  at  no  point  was  bounded  by  the  perichondrium, 
which  everywhere  appeared  to  be  perfectly  healthy." 

These  tumors  are  formed  of  serum,  or  serum  and  blood,  which  is 
effused,  not  under  the  skin,  but  under  the  perichondrium  detached 
from  the  cartilage;  the  contents  are  not  ordinarily  completely  liquid, 
but  are  liable  to  contain  fibrous  or  gelatiuiform  clots,  which  if  not 
evacuated  attach  themselves  to  the  internal  surface  of  the  sac  during 
the  process  of  union  between  the  two  surfaces.  It  was  formerly  be- 
lieved that  the  exudation  produced  a  new  formation  of  cartilage, 
sometimes  constituting  a  uniform  layer,  sometimes  small  patches 
only,  which  was  the  cause  of  the  thickening  of  the  ears.  Virchow,* 
however,  alleges,  that  the  cartilage  so  commonly  found  in  these  cases 
consists  of  detached  portions  of  greater  or  less  size,  which  remain  ad- 
herent to  the  perichondrium,  and  are  not  of  new  formation. 

A  peculiar  variety  of  otha^matoma  ought  to  be  mentioned  which 
is  not  always  easily  distinguishable  from  hyperaemia,  a  condition,  in 
the  writer's  experience,  only  met  with  in  the  insane,  where  it  is 
probably  due  to  protracted  and  violent  rubbing  of  the  auricle.  Any 
portion  of  the  perichondrium  may  be  involved,  but  it  is  usually 
limited  to  a  small  space.  Thickening  is  often  scarcely  observable, 
and  to  the  feel  it  is  not  "  doughy."  The  deep-seated  nature  of  the 
inflamed  or  congested  region,  however,  may  be  discovered  by  stretch- 
ing out  the  auricle  between  the  observer's  eye  and  a  strong  light. 
The  effusion  is  not  sufficient  to  form  a  tumor;  such  cases  seem  to 
present  the  characteristics  of  the  first  stage  of  othaematoma.  Case  V. 
is  an  example  of  this  condition. 

These  sanguineous  cysts,  as  they  are  sometimes  called,  may  be  limited 
to  a  slight  extravasation  scarcely  distinguishable  from  deep  conges- 
tion, or  they  may  consist  in  a  tumor  of  greater  or  less  dimensions. 
The  tumor,  although  not  always  consecutive  to  an  inflammatory 
process  (as  in  immediate  extravasation  from  traumatic  laceration),  is, 
however,  usually  characterized  by  more  or  less  inflammation  of  the 
cartilage  and  perichondrium  of  the  ear,  and  by  the  sudden  escape  of 
sanguineous  fluid  between  the  cartilage  and  perichondrium,  and,  it  is 
said,  into  the  substance  of  the  cartilage  itself.  The  size  of  the  tumor 
varies  from  that  of  a  Lima  bean  to  an  egg;  its  formation  is  usually 
rapid,  and  the  contents,  at  first  fluid,  show  a  marked  tendency  to  be- 
come clotted,  and  quite  often,  unless  incised,  spontaneous  rupture 
takes  place. 

'  Pathologie  des  Tumeurs,  vol.  ii.    Paris,  1867. 


1 28  OTHEMATOMA. 

In  the  milder  attacks,  extravasation  is  so  slight  that  it  has  been 
characterized  as  a  serous  oedema. 

Generally  the  outlines  of  the  outer  surface  of  the  pinna,  formed  by 
the  foldings  of  the  cartilage,  are  more  or  less  obliterated,  according 
to  the  extent  of  the  tumor;  where  there  were  ridges  and  depressions 
before,  the  surface  will  be  smooth,  and  usually  convex  even. 

The  exudation  always  takes  place,  as  far  as  the  writer's  own  experi- 
ence goes,  on  the  outer  surface  of  the  pinna,  and  seldom  affects  the 
inner  surface  at  any  period  of  the  disease.  The  swelling  in  most 
cases  begins  near  the  superior  border  of  the  pinna,  but  it  may  show 
itself  on  any  portion  of  the  exterior  surface,  including  the  concha. 
The  lobule  is  never  directly  affected,  since  it  contains  no  cartilage,  and 
the  cartilaginous  portion  of  the  external  auditory  canal  is  seldom  in- 
volved.    The  tragus  seems  to  enjoy  entire  immunity  from  attacks. 

This  selection  of  the  outer  surface  of  the  auricle  seems  to  be  owing 
to  the  greater  vascularity  of  this  region,  upon  which  the  branches  of 
the  anterior  and  posterior  auricular  arteries  ramify  and  anastomose, 
and  to  the  fact  that  it  almost  invariably  receives  the  impact,  when  the 
auricle  is  struck,  with  greatest  force.  Where  there  is  an  inflamma- 
tory movement  in  the  parts,  the  connective  tissue  on  the  inner  surface 
of  the  pinna  may  become  the  seat  of  suppurative  action,  and  an  absces 
may  form;  or,  should  perforation  of  the  cartilage  take  place,  the  con- 
tents of  the  tumor  may  pass  through  from  the  anterior  cyst,  separating 
the  perichondrium  from  the  cartilage  on  the  inner  surface,  and  escape 
into  the  connective  tissue  even. 

Symptoms  and  Course. — Subjective  symptoms  are  usually  present 
where  occlusion  of  the  external  auditory  meatus  is  produced  by 
swelling  of  the  concha;  they  consist  in  deafness— due  to  closure  of  the 
canal — and  tinnitus  aurium — from  increased  tension  of  the  membrana 
tympani.  The  extent  of  these  symptoms  in  lunatics  cannot  with 
accuracy  be  determined. 

In  the  beginning  of  an  attack,  and  during  its  progress,  the  patient 
sometimes  experiences  a  feeling  of  heat  in  the  affected  organ,  like  the 
extreme  congestion  due  to  flushing;  in  the  insane,  however,  precur- 
sory signs  are  not  likely  to  be  reported. 

When  the  invasion  takes  place,  the  affected  region  usually  presents 
a  hypereemic  appearance;  frequently  there  is  in  lunatics  a  very  decided 
flow  of  blood  toward  the  head,  producing  great  capillary  turgescence 
of  the  face,  ears,  and  eyes;  in  some  instances  an  effusion  of  blood 
beneath  the  conjunctiva  of  the  eye  has  been  known  to  occur  simul- 
taneously with  the  appearance  of  the  othaematoma.  In  the  more 
severe  ca^es,  where  the  characteristic  effusion  takes  place  rapidly  with 


OTHiEMATOMA.  129 

inflammatory  action,  there  is  often  an  elevation  of  temperature;  and 
in  nearly  all  instances  the  integument  assumes  a  bluish  or  purplish 
hue.  The  affected  organ  is  seldom  very  painful,  even  where  the 
tumor  is  greatly  distended  or  roughly  handled,  especially  in  boxers  and 
lunatics,  where  the  parts  have  been  subject  to  rough  treatment  from 
repeated  contusions;  in  the  latter,  however,  the  ears  are  wanting  in 
sensibility  at  all  times.  The  writer  has,  however,  frequently  observed 
that  sensibility  is  very  much  exalted  in  some  cases  occurring  in  sane 
persons. 

Othaematoma  occurring  in  pugilists  differs  in  no  respect  from  that 
found  in  lunatics,  its  progress  being  influenced  by  the  general  con- 
dition and  habits  of  the  patient  in  both  instances. 

The  retro-active  consequences  of  this  local  trouble  in  the  insane 
need  not  be  considered  here,  yet  it  is  worthy  of  note  that  the 
posterior  auricular  artery,  through  one  of  its  branches,  the  stylo- 
mastoid, communicates  with  the  middle  meningeal  by  anastomosis, 
thus  establishing  a  significant  and  important  relationship  between 
the  ear  and  the  meninges  of  the  brain.  In  the  mentally  sane 
this  becomes  a  factor  of  serious  import,  and  should  not  be  over- 
looked; besides,  more  or  less  general  nervous  sympathy  may  exist  in 
sane  patients. 

Parts  contiguous  to  the  ear  are  sometimes  implicated  in  an  exten- 
sion of  the  inflammatory  process;  neuralgia  may  be  kindled  into 
action,  and  general  febrile  action  may  supervene.  "Whilst  othaema- 
toma may  be  produced  by  disease  or  wounding  of  the  cartilage  of  the 
external  auditory  canal,  it  seldom  extends  itself  to  these  parts  from 
the  pinna;  and  the  middle  ear,  so  far  as  is  known  to  the  writer  at 
least,  has  never  been  invaded  by  an  extensive  inroad  of  the  inflamma- 
tory process. 

The  progress  of  the  tumor  varies  very  much  ;  it  may  rise  to  a  con- 
siderable size  in  the  course  of  a  few  hours,  and  when  first  seen  may 
be  as  large  as  an  almond  or  a  walnut.  Sometimes  the  distention 
continues  to  progress  rapidly,  the  walls  becoming  thinner  in  conse- 
quence of  the  stretching,  until,  finally,  in  the  worst  cases,  they  under- 
go spontaneous  rupture  unless  relieved  by  an  operation.  In  asylum 
cases  it  is  not  unusual  to  allow  the  cyst  to  burst  in  this  manner;  thus 
of  the  twenty-four  cases  reported  by  Hun,  fifteen  ruptured  spontane- 
ously ;  in  one  of  them  the  left  ear  burst  on  the  twelfth  day  at  the 
upper  part  of  the  concha,  while  the  patient  was  sitting  in  a  chair, 
and  the  contents  "were  thrown  to  the  ceiling,  a  distance  of  twelve 
feet,  so  as  to  stain  the  plaster." 

These  tumors  are,  however,  frequently  without  some  of  the  symp- 
9 


130  OTHEMATOMA. 

toms  of  inflammatory  action,  passing  through  all  of  the  stages  of 
the  disease  without  either  heat  or  pain  being  experienced  by  the 
patient.  This  variety  manifests  a  disposition  to  develop  slowly,  and 
has  a  tendency  to  spread  itself  laterally  rather  than  in  thickness,  as. 
in  Case  I. 

The  contents  of  the  tumor,  even  when  at  first  serous,  usually 
become  sero-sanguinolent  sooner  or  later.  In  some  instances,  how- 
ever, the  serous  character  continues  throughout.  In  most  cases  an 
early  formation  of  coagula  takes  place  in  the  tumor,  which,  not  being 
reabsorbed,  increases  ensuing  deformity.  In  the  milder  form  of  the 
affection,  sometimes  described  as  *'  cedematous,"  but  little  fibrous 
tissue  remains,  re-absorption  being  more  complete  ;  such  cases  seem 
to  pass  through  all  of  the  stages  with  but  moderate  inflammatory 
action. 

The  wound  which  affords  an  outlet  for  the  contents  of  these  cysts, 
when  they  require  any,  whether  from  puncture  or  due  to  spontane- 
ous rupture,  has  no  tendency  to  remain  open,  and  the  cavity, 
therefore,  sometimes  refills  in  the  course  of  a  few  hours  ;  on  the  other 
hand,  in  certain  cases  the  cyst  pours  out  fluid  so  rapidly  that  a  dis- 
charge constantly  trickles  down  from  the  opening,  thus  preventing 
the  wound  from  closing. 

The  duration  of  othcBmatoma  will  of  course  vary  greatly,  depending 
as  it  does  on  the  severity  of  the  case,  the  rapidity  of  reabsorption, 
and  the  habits  of  the  patient  ;  thus  in  lunatics,  inebriates,  and 
boxers  the  organ  is  liable  to  repeated  contusions,  giving  rise  to  aggra- 
vations which  may  retard  the  cure.  Sometimes  reabsorption  comes 
to  a  stand-still,  and  a  considerable  tumor  remains  for  an  indefinite 
period  of  time.  Case  II.  is  one  of  this  kind  which  was  seen  by  the 
writer. 

Termination. — In  a  very  considerable  number  of  cases  the  disease 
will  terminate  spontaneously  in  from  four  to  eight  weeks,  depending 
somewhat  on  the  extent  of  perichondrium  affected  and  the  quantity 
of  the  effusion  ;  othaematoma,  however,  cannot  be  said  to  have  any 
regular  course  where  it  occurs  in  irresponsible  or  uncontrollable  pa- 
tients. It  will  be  found  that  among  any  considerable  collection  of 
lunatics  or  prize-fighters,  no  very  small  number  have  their  ears  more 
or  less  deformed  by  previous  attacks  of  othaematoma.  In  some 
lunatics,  where  well-marked  deformity  presents  itself  in  one  auricle, 
the  other  will  be  found  so  slightly  deranged  as  to  be  liable  to  escape 
detection  altogether  unless  closely  scrutinized,  and  in  others  scarcely 
any  observable  thickening  will  be  found  in  the  affected  organ,  the 
deeper  coloring  alone  affording  evidence  to  the  eye,  whilst  the  slight 


OTHEMATOMA.  131 

induration,  thickening,  and  immobility  of  the  skin  are  not  to  be 
detected  without  careful  handling. 

It  seems  exceedingly  probable  that,  in  certain  cases  where  the  alien- 
ist is  in  doubt  as  to  the  sanity  of  a  patient,  valuable  confirmatory 
evidence  of  previous  mental  trouble  might  be  obtained  by  an  exami- 
nation of  the  ears.  Where  the  deformity  is  great,  in  consequence  of 
an  extensive  area  of  cartilage  having  been  exposed  by  detachment  of 
its  perichondrium,  the  skin  on  the  outer  surface  will  usually  be  found 
to  be  immovable,  whilst  that  on  the  inner  surface  remains  unchanged. 
In  these  cases  the  concha  is  liable  to  be  much  reduced  in  dimensions, 
its  posterior  wall  being  often  so  much  thickened  that  a  narrow  ver- 
tical slit  only  remains  in  front  of  the  meatus  externus,  preventing 
the  introduction  of  any  but  a  speculum  of  the  smallest  size.  It  is 
scarcely  necessary  to  add  that  the  deformity  arising  from  othaematoma 
is  not  influenced  by  the  mental  condition  of  the  patient. 

The  characteristic  deformity  resulting  from  othaematoma  is  well 
shown  in  Cases  VI.,  VII.,  VIII.,  IX.,  X. 

In  its  regressive  course,  the  contents  of  the  tumor  are  gradually 
reabsorbed  or  a  puncture  gives  them  exit,  the  surfaces  gradually  come 
in  contact,  and  the  outlines  of  the  cartilage  begin  to  reappear,  but 
more  or  less  altered  in  distinctness.  If  obliteration  of  the  cavity  is 
accomplished  by  a  moderate  exudation  of  lymph  uniting  its  walls, 
the  deformity  will  be  slight,  especially  if  the  tumor  has  been  but 
moderately  distended  by  fluid.  On  the  other  hand,  where  the  peri- 
chondrium has  been  greatly  stretched  by  extreme  distention  of  the  sac, 
it  contracts  upon  itself  as  reabsorption  takes  place,  and  adaptation  to 
the  cartilage  as  before  cannot  occur;  the  misshappen  appearance  of  the 
cartilage  increases  with  the  continued  contraction  during  the  process 
of  adhesion.  The  ear  finally  becomes  indurated,  and  the  skin  on  its 
outer  surface  is  immovable^  and  follows  the  outlines  of  the  distorted 
cartilage  underneath.  Sometimes  the  organized  lymph  which  ob- 
literates the  cavity  enormously  increases  the  thickness  of  the  auricle, 
an  example  of  which  condition  is  shown  in  Fig.  24.  Where  a  thin  plastic 
layer  only  intervenes  finally,  as  occurred  in  Case  XIV.,  the  auricle  is 
likely  to  be  reduced  in  size,  and  becomes  comparatively  thin  and 
shrivelled;  in  either  case  permanent  and  characteristic  deformity  re- 
sults. 

In  some  cases,  where  the  effusion  has  been  slight  or  imperceptible 
even,  the  plastic  exudation  does  not  form  a  laj^er  of  any  great  magni- 
tude, and  but  little  thickening  is  left  behind;  the  mobility  of  the 
skin  is  less  affected,  and  consequently  the  ensuing  deformity  ia 
scarcely  recognizable. 


132  OTHEMATOMA. 

It  should  be  mentioned,  in  concluding  these  remarks  on  the  pro- 
gress and  termination  of  the  disease,  that  in  some  cases  which  the 
writer  examined  among  insane  persons  the  othaematoma  was  observed 
at  first  to  make  but  slow  progess,  remaining  stationary  even  for  sev- 
eral weeks,  when,  without  any  apparent  cause  or  active  inflammatory 
symptoms,  it  would  gradually  increase  in  size.  It  is  extremely  prob- 
able that  this  was  caused  by  some  new  trauma  to  the  auricle. 

Diagnosis. — The  "  Asylum  Ear "'  was,  by  all  observers  half  a  cen- 
tury ago,  regarded  as  a  curiosity  simply,  and  even  at  the  present  time 
it  seems  very  often  to  escape  attention  entirely,  or  to  be  merely  en- 
tered in  asylum  case-books  as  a  nondescript  phenomenon.  It  is  to  be 
hoped  that  a  want  of  knowledge  in  this  respect  will  not  long  prevail 
where  the  disease  is  liable  to  occur,  and  where  treatment  may  do 
much  to  ameliorate  the  condition  of  the  patient.  In  fact,  the  want  of 
adequate  knowledge  in  regard  to  othaematoma  seems  scarcely  any 
longer  excusable  when  we  consider  the  light  that  has  been  thrown 
upon  the  subject  during  the  past  twenty  years  by  various  authors. 

In  distinguishing  this  affection  from  erysipelas,  phlegmonous  in- 
flammation, frost-bite,  burns,  eczema,  tubercular  syphilis,  and  other 
cutaneous  affections,  one  almost  constant  causative  agency  should  be 
flrst  sought  for,  namely,  trauma.  Whether  predisposing  condibions 
are  present  or  not,  the  history  will  give  unmistakable  evidences  of 
this  factor.  There  may  often  be  reasons  for  suppressing  the  truth; 
persons  may  desire  to  conceal  the  fact  of  blows  having  been  admin- 
istered, or  they  may  have  been  so  slight  as  to  have  escaped  attention, 
nevertheless  where  othaematoma  is  suspected,  inquiries  in  this  direc- 
tion should  be  diligently  pressed. 

The  essential  nature  of  the  affection  depending  on  a  perichondritis 
of  the  cartilage  of  the  auricle,  its  existence  may  be  readily  detected 
by  examining  the  contents  of  the  tumor,  which  will  be  found  to  be 
serous  or  sero-sanguinolent.  These  tumors  are  usually  of  rapid  for- 
mation, and  speedily  refill  again  on  being  evacuated.  It  will  be  found 
that  they  have  well-defined  and  resisting  walls,  a  fact  which  may  be 
determined  by  exploring  the  walls  of  the  tumor  with  a  probe  after  it 
has  been  incised  or  ruptured. 

Abscesses  or  blood  extravasations  rarely  develop  in  the  scanty  con- 
nective tissue  of  the  auricle,  and  they  are  much  more  limited  in  di- 
mensions than  othaematoma;  their  walls,  moreover,  give  way  to 
moderate  distention,  and  their  progress  will  be  found  to  be  less  pro- 
tracted than  the  tumors  under  consideration. 

Suppurative  perichondritis  has  been  alluded  to  by  writers,  but  pus 
is  seldom  found  in  these   cysts;  extravasated   blood  may,  however. 


OTHEMATOMA.  133 

become  putrescent,  or  a  perforation  of  the  walls  of  the  cyst  may 
afford  a  communication  with  an  abscess  behind  the  cartilage  of  the 
auricle,  or  with  the  deeper  parts  about  its  attachment  to  the  tem- 
poral bone. 

Abscesses,  however,  may  develop  in  the  post-auricular  connective 
tissue  during  the  progress  of  cases  of  marked  inflammatory  tendency 
or  as  a  result  of  contusions.  In  such  cases,  or  where  swelling  occurs 
without  maturation,  an  asymmetrical  prominence  of  the  auricle 
occurs.    Case  IV.  is  one  in  point. 

In  many  cases  of  othaematoma  the  auricle  does  not  stand  off  from 
the  head,  the  disease  being  limited  to  the  wing  of  the  ear  through- 
out. Parts  contiguous  to  the  auricle  are  always  the  last  to  be  af- 
fected, if  invaded  at  all.  The  trouble  may  be  distinguished  fr/)m 
erysipelas,  for  which  it  was  formerly  sometimes  taken,  by  its  well- 
defined  sacculated  appearance  and  the  absence  of  superficial  changes 
common  in  erysipelas.  Eczema  and  erysipelas,  unlike  othaematoma, 
are  liable  to  extend  into  the  external  auditory  canal,  while  the  latter, 
at  most,  usually,  occludes  the  meatus  by  the  encroachment  of  its  sac. 
The  cutaneous  affections  mentioned  above,  moreover,  frequently  in- 
vade the  neighboring  parts,  especially  the  inner  surface  of  the  auri- 
cle; none  of  them,  however,  leave  the  deformity  which  characterizes 
othaematoma.  NaBvi  may  resemble  othaematoma  very  closely  in  some 
instances.  The  writer  once  saw  a  case  of  thi^  kind  occurring  in  a 
woman  where  a  large  portion  of  the  auricle  was  involved.  The 
marked  pulsation  and  absence  of  fluctuation  in  such  a  case  would 
serve  to  distinguish  it  from  othaematoma.  The  age  of  the  patient 
should  be  considered  in  arriving  at  a  diagnosis;  thus  eczema,  for 
example,  is  most  frequent  in  infancy  and  childhood,  whilst  othsema- 
toma  is  more  particularly  a  disease  of  adult  life. 

Prognosis. — This  affection  probably  has  no  prognostic  value  in 
respect  to  the  occurrence,  course,  or  duration  of  insanity.  The 
trouble  cannot  be  said  to  augur  against  recovery,  since  it  oc- 
curs in  dementia  when  bodily  health  is  improving,  nor  is  it 
obnoxious  to  any  particular  form  of  insanity.  In  Hun's  reported 
cases,  nine  of  the  patients  died  insane  in  the  asylum,  nine  were  dis- 
charged unimproved,  and  six  remained  when  the  report  was  made — 
one  of  them  in  a  state  of  dementia. 

Generally  the  disease  runs  the  course  already  described,  without  any 
complication  that  endangers  life,  although,  when  extravasated  blood 
becomes  putrescent,  there  may  be  danger  of  septic  poisoning. 

Hearing  undoubtedly  suffers  considerable  impairment  in  some  cases 
through  the  deformity  of  the  outstanding  cartilaginous  framework  of 


134  OTHiEMATOMA. 

the  ear.  In  the  case  of  a  pugilist  examined  by  the  writer,  whose 
auricle  was  greatly  disfigured,  there  were  permanent  defects  in  this 
regard,  apparently  due  to  the  interference  with  the  normal  tension  of 
the  membrana  tympani — vide  Case  XX. 

Recurrence  of  the  tumor  is,  of  course,  impossible,  where  complete 
obliteration  of  the  secreting  surfaces  has  occurred,  although  repeated 
contusions  in  an  auricle  previously  affected  may  give  rise  to  more  or 
less  inflammation  of  the  organ.  In  several  prize-fighters  examined, 
where  ears  had  been  previously  the  seat  of  othaematoma,  constant 
bruising  of  the  organ  seemed  to  occasion  very  little  local  disturbance. 

Treatment. — The  treatment  of  contusions  of  the  ears,  of  course, 
attracted .  the  attention  of  ancient  physicians.  Thus  Paulus  of 
^gina,  in  treating  of  these  injuries,  did  not  think  any  treatment 
required;  since  it  was  necessary,  however,  to  do  something,  he 
recommended  that  a  local  application  of  myrrh,  aloes,  etc.,  be 
employed.  Hippocrates  found  that  some  of  these  injuries  were  much 
more  grave  in  their  nature  than  others,  and  he  seems  not  to  have 
found  their  treatment  satisfactory.  He  shows  a  want  of  faith  in 
bandages  or  cataplasms,  as  he  believed  that  they  favored  the  forma- 
tion of  abscesses  and  established  suppuration;  the  ear,  indeed,  seemed 
to  stand  in  need  of  such  applications  less  than  any  other  part,  and 
none  were  sometimes  good  treatment.  When  suppuration  (effusion?) 
threatened,  there  need  be  no  haste  in  making  an  incision,  for  often  the 
matter  (?)  tvas  absorbed  again  [italics  the  writer's].  Were  he  forced 
to  open  it  (the  tumor?)  he  preferred  transfixion  with  a  cautery,  since 
by  means  of  this  method  the  parts  get  well  soonest,  and  yet  it  should 
be  well  understood  that  deformity  will  ensue  and  the  ear  be  smaller 
than  the  other  if  thus  burnt  through.  If  an  incision  were  decided  on 
it  should  be  freely  made  on  the  upper  (outer?)  side,  for,  he  says,  the 
pus  (?)  is  found  to  be  surrounded  with  a  thicker  covering  than  one 
would  have  supposed.  After  incisions,  which  may  not  always  be  fol- 
lowed by  evacuation  of  mucus  (serum?),  cataplasms  and  pledgets  are 
to  be  avoided.  The  true  nature  of  othaematoma  was  unknown  in  the 
time  of  Hippocrates,  and  in  tlie  treatment  of  the  affection  he  was 
probably  not  aware  that  a  separation  of  the  perichondrium  from  the 
cartilage  takes  place,  and  that  the  detached  surfaces  supply  the  serum, 
which  he  wrongly  believed  to  consist  of  mucus. 

In  the  treatment  of  othaematoma  in  insane  and  intemperate  persons, 
among  whom  it  mostly  occurs,  besides  the  difficulties  encountered  in 
controlling  the  actions  of  the  patient,  mental  disease  and  intemperate 
habits  exert  an  unfavorable  influence,  and  thus  delay  recovery.  Insane 
persons  are  more  obnoxious  to  the  trouble  when  under  great  excite- 


OTHEMATOMA.  135 

ment,  as  in  acute  dementia;  and  their  violent  arid  restless  movements 
interfere  very  much  with  treatment,  whilst  pugilists  are  indifferent, 
and  generally  neglect  any  advice  given  them.  It  is  a  safe  rule  in  the 
beginning  to  be  in  no  haste  to  interfere  unless  rupture  of  the  sac  be 
imminent,  since  in  a  certain  number  of  cases  a  manifest  tendency  to 
spontaneous  recovery  exists. 

In  laying  out  any  plan  of  treatment  in  this  disease,  it  will  be  well 
to  remember  that  whatever  the  supposed  cause  or  causes  may  be,  we 
have  to  deal  with  a  perichondritis,  in  the  treatment  of  which  we  should 
be  guided  rather  by  its  character  than  by  its  causes.  And  further- 
more, one  should  be  on  their  guard  in  respect  to  the  strong  tendency 
to  interfere  in  these  cases;  this  is  well  expressed  in  a  paper  on  the 
subject  by  Wallis.'  This  author  treated  these  tumors  as  abscesses, 
and  after  incision  they  were  poulticed  and  treated  with  stimulating 
lotions,  "  but  almost  always  with  unfavorable  results — gangrene,  and 
various  destruction  of  the  cartilage,  and  not  rarely  death,  was  the 
end."  This  experience  induced  Wallis  to  fall  back  on  nutritious 
diet,  mild  cathartics,  and  the  local  application  of  lead  wash — in  all 
other  respects  treating  the  swelling  as  a  noli  me  tatigere.  This  treat- 
ment, continued  for  weeks,  was  successful  in  a  number  of  cases. 
Pischer  came  to  the  conclusion  that  eight  weeks'  treatment  affects 
neither  the  termination  nor  the  duration  of  the  disease,  an  opinion 
coinciding  closely  with  the  one  held  by  Marce,  whose  belief  was  that 
othaematoma  is  not  influenced  by  any  treatment,  but  usually  remains 
for  about  four  months.  In  regard  to  the  views  above  cited,  however, 
it  should  be  said  that  the  fatal  results  alluded  to  by  Wallis  are  quite 
exceptional,  similar  experiences  being  unknown  to  other  writers, 
while  Fischer  and  Marce  seem  to  have  carried  the  expectant  plan  too 
far,  since  no  treatment  is  not  good  practice  in  all  cases. 

In  its  aggressive  stage  the  observer  is  seldom  offered  an  opportunity 
to  take  cognizance  of  the  incipient  symptoms.  Usually  a  tumor  is 
already  found  to  exist,  and  the  first  consideration  will  then  be  to 
limit  its  extension,  if  possible.  If  it  is  found  that  the  quantity  of 
the  serous  or  serosangu indent  exudation  is  not  great,  we  may  pre- 
scribe rest  for  the  patient,  and  administer  small  doses  of  the  tincture 
of  aconite  root  with  a  view  to  arrest  the  activity  of  the  circulation 
of  blood  about  the  head.  Locally  the  affected  region,  and  beyond 
even,  may  be  enveloped  with  a  coating  of  collodion,  the  gentle  and 
uniform  pressure  produced  by  its  contraction  acting  as  a  compress, 
;and  thus  promoting  absorption. 

'  Loc.  cit. 


136  OTHiEMATOMA. 

Case  XI.  is  a  good  illustration  of  the  treatment  and  progress  in  a 
case  of  this  kind. 

Eeabsorption  is- sometimes  retarded  by  the  general  condition  of  the 
patient,  and  it  is  alleged  by  some  authors  that  a  comparatively  scanty 
distribution  of  lymphatics  characterizes  this  region.  Whenever  this 
tendency  manifests  itself,  it  will  be  well  to  employ  measures  likely  to 
hasten  reabsorption.  We  may  act  on  the  presumption  here  that  the 
inflammatory  reaction  frequently  attending  the  regressive  stage  is 
wanting  or  inefficient,  and  proceed  to  employ  massage  or  pressure.  In 
the  writer's  own  experience,  the  latter  has  been  generally  unsatis- 
factory. 

The  massage  treatment  consists  in  pressing  and  rolling  the  affected 
portion  of  the  pinna  between  the  thumb  and  forefinger  for  some  min- 
utes or  more  at  a  time.  This  manipulation  is  usually  unattended  by 
pain,  and,  moreover,  has  this  advantage,  that  it  can,  when  necessary ,^ 
be  entrusted  to  sane  patients  themselves.  At  first  it  may  be  practised 
once  or  twice  daily,  and  afterward  more  frequently,  the  length  of  each 
seance  being  extended  as  treatment  progresses. 

The  behavior  of  these  tumors  under  continued  and  even  severe 
bruisings  is  instructive.  The  writer's  observations  of  othaematomata 
in  pugilists  demonstrated  the  fact  that  recovery  is  not  impossible^ 
under  apparently  unfavorable  conditions,  although  it  should  be  added 
that  unsightly  deformity  remained. 

In  resorting  to  methods  calculated  to  increase  absorption,  however,, 
care  must  be  exercised  lest  they  increase  unduly  the  local  irritation. 
In  relation  to  this  matter,  the  following  paragraph  is  suggestive  : 
"  Physiologically  the  membrane  of  serous  cavities  secretes  a  serous 
fluid,  which  is  taken  up  again  by  the  vessels  with  great  facility  ;  this 
faculty  of  reabsorption  is  demonstrated  by  the  rapid  disappearance  of 
injected  fluids.  But  if  the  serous  membrane  is  inflamed,  the  re- 
absorption of  an  injected  fluid  is  impossible  (Rindfleisch),  and  the  irri- 
tation of  the  serous  membrane  determines  an  abundant  secretion. 
Even  a  slight  irritation  is  sufficient  to  transform  a  serous  bursa  into  a 
cystic  cavity.  Such  a  transformation  of  a  subcutaneous  serous  bursa 
is  known  as  a  hygroma,  and  may  be  called  a  tumor  because  of  its  ten- 
dency to  persist  inJiefinitely." '  If  extravasation  in  the  beginning 
goes  on  rapidly,  threatening  to  denude  the  cartilage  more  and  more, 
or  where  reabsorption  comes  to  a  standstill,  an  aspirating  needle  may 
be  inserted  into  its  most  dependent  part  and  the  fluid  evacuated  ;  the 
subsequent  treatment  should  then  consist  in  the  methods  already 

'  Cornil  and  Ranvier :  Pathological  Histology,  pp.  167,  168.  Philadelphia, 
1880. 


OTHEMATOMA.  137 

recommended.  The  evacuation  of  fluid  may  be  repeated  as  often  as 
the  sac  refills.  The  operation  can  usually  be  performed  with  the 
ordinary  hypodermic  syringe. 

When  the  tumor  is  large  and  contains  a  considerable  clot,  it  is  best 
to  make  an  incision  large  enough  to  permit  the  contents,  including 
the  clot,  to  escape  ;  and,  since  the  tumor  is  almost  sure  to  refill  again, 
a  silk  seton  may  be  passed  through  the  opening  thus  made  and 
brought  out  again,  above,  to  insure  drainage.  The  wounds,  having  a 
strong  tendency  to  reunite,  should  be  kept  open  by  occasionally 
drawing  the  seton  through  the  tumor  whilst  pressing  out  the  con- 
tents. As  soon  as  the  secretion  lessens,  its  removal  will  be  best 
accomplished  by  aspiration.  It  was  formerly  recommended  to  bring- 
about  adhesive  inflammation  by  keeping  up  irritation  with  the  seton, 
but  this  can  be  much  better  accomplished  by  massage. 

When  the  above  treatment  is  judiciously  employed  we  may  expect 
to  witness  a  gradual  diminution  of  the  tumor  and  complete  reabsorp- 
tion  of  the  fluid  in  three  or  four  weeks  ;  and,  moreover,  it  is  believed 
that  much  less  disfigurement  will  ensue  than  occurs  in  cases  allowed 
to  run  their  course  without  such  aid.  The  longer  an  actively  pro- 
gressing tumor  is  permitted  to  go  on  toward  spontaneous  rupture,  the 
greater  will  be  the  separation  of  the  perichondrium  from  the  carti- 
lage, and  consequently  the  greater  the  ensuing  deformity. 

"Sometimes  it  happens  that  the  regressive  stage  runs  on  into  a 
chronic  condition,  and  the  walls  of  the  cyst  fail  to  unite,  or  else  a 
permanent  sinus  remains.  Under  these  circumstances,  it  will  be 
necessary  to  destroy  the  secreting  surface  of  the  cyst.  This  may  be 
accomplished  either  by  the  application  of  escharotics  or  irritants  to 
the  walls  of  the  cyst.  In  regard  to  the  selection  of  an  irritant  for  this, 
purpose,  none  has  been  found  equal  to  a  strong  solution  of  iodine  in 
the  author's  experience.  A  free  incision  into  the  tumor  should  be 
made,  the  cavity  cleaned  out,  and  its  surface  freely  painted  with 
Churchill's  solution  of  iodine. 

The  walls  of  the  tumor  are  afterward  to  be  kept  in  contact  by  pres- 
sure. The  injection  of  small  quantities  of  the  tincture  of  iodine  into 
these  tumors  has  proved  to  be  temporizing  and  unsuccessful.  Case 
II.  is  an  example  of  the  advantages  of  the  method  recommended 
above.  When  the  operation  already  described  fails,  or  for  any  reason 
seems  inadvisable,  the  surface  of  the  walls  of  the  tumor  may  be 
abraded  throughout  with  the  fenestrated  cutting  scraper,  as  in 
Case  III.  Where  any  projecting  edges  or  sharp  folds  of  the  cartilage 
prevent  the  walls  coming  together,  they  may,  where  the  correcting 
of  deformity  is  desired,  be  extirpated  by  dissection. 


138  OTHEMATOMA. 

After  the  operation,  the  walls  should  be  kept  in  contact  by  bandag- 
ing (pressure).  In  the  writer^s  experience,  otoplastic  operations  can 
be  performed  with  considerable  freedom  in  these  cases  without  fear 
of  undue  reactive  inflammation,  the  wounds  healing  readily  in  the 
insane,  even  where  low  recuperative  .action  might  be  expected  to 
exist. 

The  cases  which  are  given  below,  occurring  both  in  the  mentally 
sane  and  in  the  insane,  while  showing  that  the  affection  is  ob- 
noxious to  both  classes,  teach  us  at  the  same  time  that  the  trouble 
in  the  latter  is  subject  to  induences  which  usually  render  its  manage- 
ment more  difficult  than  in  the  former.  In  the  treatment  of  othae- 
matoma  in  the  insane,  it  would  be  well  to  keep  in  mind  that, 
subsequently  to  the  period  of  greatest  local  congestion,  there  is  very 
often,  probably,  a  decrease  in  the  temperature  of  the  auricle,  which 
may  be  due  to  more  or  less  complete  restoration  of  vaso-motor  domin- 
ance, a  condition  scarcely  distinguishable  to  the  eye  from  active 
turgescence,  although  to  the  touch  the  parts  are  cold  even.  The 
writer  had  no  opportunity  to  test  this  matter  by  thermometrical  ob- 
servations, and  is,  therefore,  unable  to  state  the  exact  degree  of 
depression  which  probably  exists. 

One  should  not  be  in  haste  to  interfere  in  these  cases  ;  in  general 
it  may  be  said  that  the  dictum  of  Hippocrates,  namely,  that  the  em- 
ployment of  cataplasms  and  pledgets  are  to  be  avoided,  is  as  safe  a 
guide  now  as  it  was  in  his  own  day.  But  while  excessive  poulticing 
is  to  be  avoided,  there  are  probably  some  few  cases  where  hot  fomenta- 
tions or  light  emollients  of  various  kinds  may,  when  judiciously 
applied,  prove  grateful  in  an  auricle  higlily  inflamed.  As  regards 
pledgets,  however,  their  employment  is  always  liable  to  do  harm, 
since  they  give  rise  to  undue  irritation  if  employed  early,  and  the  dis- 
tention produced  by  them  later  on,  when  thrust  into  the  cyst, 
prevents  the  walls  of  the  tumor  coming  together  and  adhering  to  each 
other.  The  employment  of  ointment  has  not,  seemingly,  been  a 
favorite  mode  of  treatment,  but  belladonna  ointment  would  no  doubt 
be  beneficial  where  the  cutaneous  circulation  is  languid.  In  the  re- 
gressive stage,  dilute  tincture  of  arnica  is  of  service,  as  in  other  con- 
tusions. 

Where  suppurative  processes  arise,  as  they  sometimes  do,  in  the 
inner  portion  of  the  auricle,  the  post-aural  region,  or  contiguous  to 
the  cartilaginous  canal,  the  calcium  sulphide  (Calx  Sulphurata  of 
the  Pharmacopoeia)  is  indicated. 

That  these  patients  should  be  kept  quiet,  and  usually  in  a  restful 
attitude,  need  not  be  dwelt  on  here.     The  self-infliction  of  further 


OTHEMATOMA. 


139 


injury,  or  its  production  by  others,  among  insane  persons,  should  be 
prevented.  Attention  to  general  health,  of  course,  must  not  be  over- 
looked. 

In  conclusion,  the  introduction  of  a  few  cases,  illustrating  the  more 
important  points  which  it  has  been  endeavored  to  bring  out  in  the 
foregoing  remarks,  may  be  found  of  interest. 

Case  I. — W.  W ,  an  Englishman,  43  years  of  age,  by  occu- 
pation a  negro  minstrel;  health  good,  and  he  claims  to  have  no 
t)ad  habits;  never  had   any  aural  disease  before;  came  to  the   New 


Fig.  so. 


York  Eye  and  Ear  Infirmary  May  4th,  1880.  and  stated  that  two 
weeks  ago,  wliile  washing  the  burnt  cork  from  his  face,  he  had  felt  a 
slight  soreness  on  the  top  of  the  right  auricle.  On  examination,  he 
found  a  small  tumor  on  the  outer  aspect  of  the  auricle,  which  after- 
ward gradually  increased  in  size  until  it  oblitera'ed  the  antihelix,  and 
finally  became  about  one-half  an  inch  in  thickness.  On  shaking  his 
head,  the  patient  could  "feel  the  contents  of  the  tumor  rattle.^' 
The  physician  under  whose  care  the  patient  first  came  had  painted 


140  OTHiEMATOMA. 

the  tumor  with  the  tincture  of  iodine  for  the  first  few  days,  and  it  had 
decreased  somewhat  in  size.  When  the  iodine  stains  disappeared,  the 
color  of  the  tumor  was  found  to  be  but  little  more  red  than  normal, 
but  its  walls  were  thickened.  Under  the  expectant  plan,  the  fluid 
continued  to  be  reabsorbed  quite  rapidly,  and  later  on  the  contents 
had  a  doughy  feel.  During  the  next  four  weeks,  the  patient  occa- 
sionally painted  the  ear  with  tincture  of  iodine,  and  it  diminished 
notably  in  size.  Thickening  and  immobility  of  tha  integument,  how- 
ever, remained.  There  was  no  shrivelling  of  the  cartilage,  and  but 
little  deformity  from  the  remaining  induration  of  the  parts.  It  is  the 
belief  of  the  patient  that  the  auricle,  previous  to  the  beginning  of  the 
swelling,  had  been  struck  a  slight  blow  by  a  papier-mache  stove, 
which  he  had  to  throw  upon  his  shoulder  during  a  play. 

Fig.  30  represents  the  appearance  of  the  ear  immediately  after  the 
tumor  had  commenced  to  subside. 

In  six  weeks  from  the  first  appearance  of  the  tumor,  there  remained 
but  a  very  slight  thickening  of  the  tissues.  No  fluid  was  present  and 
no  deformity  of  the  auricle.  It  will  be  interesting  here  to  state  that 
this  same  patient  came  to  the  author  recently  (April  27th,  1887)  for 
treatment,  with  an  othaematoma  of  the  left;  ear.  Patient  had  noticed 
the  swelling  two  weeks  before  and  attributed  its  presence  to  the  rather 
hard  rubbing  of  the  auricle,  necessary  for  removing  the  burnt  cork. 
Treatment  consisted  at  first  in  drawing  off  the  fluid  contents  with  a 
hypodermic  syringe.  This  was  done  three  times,  bloody  serum  being 
drawn  off  on  each  occasion.  The  tumor  was  also  painted  with  col- 
lodion at  first,  and  a  week  later  massage  employed.  The  drawing  off 
of  the  fluid  contained  in  the  tumor  did  not  apparently  result  in  any 
permanent  reduction  of  its  size,  as  this  quickly  collected  again. 
Four  weeks  after  the  patient  was  first  seen,  there  remained  a  slight 
thickening  of  the  tissues,  the  fluid  being  nearly  absorbed.  Massage 
was  continually  employed  together  with  the  application  of  mercurial 
ointment.     The  result  was  very  satisfactory. 

Case   II. — Charlotte  K ,  aged  39,  was  admitted   to  the   New 

York  City  Lunatic  Asylum  in  May,  1880,  when  suffering  from 
her  first  attack  of  acute  melancholia.  She  had  delusions  of  persecu- 
tion and  suicidal  tendencies,  was  subject  to  exacerbations  of  excite- 
ment, during  which  she  was  violent  and  destructive  until  quieted  by 
large  doses  of  sedatives.  In  June,  1883,  haematoma  commenced  iu 
the  left  ear,  which  ran  its  course  in  two  months  without  any  particu- 
lar treatment,  leaving  much  deformity.  On  September  12th,  1883, 
othaematoma  commenced  in  the  right  ear  ;  at  first  it  was  intensely 
red,  but  finally  became  purplish  in  appearance.     No  treatment. 

October  31st.  —  The  patient  was  examined  by  the  writer  and  a  con- 
siderable collection  of  fluctuating  fluid  was  detected  in  a  cyst,  over 
an  inch  in  length,  on  the  outer  surface  of  the  right  auricle.  The 
fluid  was  evacuated  by  a  free  incision,  the  walls  of  the  cyst  painted 
with  Churchill's  solution  of  iodine,  and  the  auricle  bandaged  to  the 
head  so  as  to  cause  a  moderate  amount  of  pressure.  By  November  3d 
the  walls  were  adherent,  and  on  November  9th  the  wound  was  found 
healing  by  granulation.     When  the  writer  last  saw  the  ear,  on  No- 


OTHEMATOMA.  141 

vember  23d,  the  sac  was  entirely  obliterated.  There  was  scarcely  any 
deformity. 

In  some  instances  a  sinus  remains,  affording  a  serous  discharge 
which  may  continue  for  an  indefinite  period.  The  following  is  a  case 
of  this  kind  : 

Case   III. — Annie   M ,   aged   35   was   admitted  to  the   New 

York  City  Lunatic  Asylum,  March,  1879,  with  acute  mania. 
Soon  afterward,  on  refusing  food,  was  forcibly  fed — the  process  con- 
sisting in  placing  the  head  of  the  patient  under  the  left  arm  of  the 
operator,  while  with  his  left  hand  a  wedge  is  held  in  the  patient's 
mouth,  and  with  the  right  hand  the  feeding  tube  is  inserted.  Subse- 
quently hsematoma  developed  in  the  left  ear.  Although  it  seems 
probable  that  the  ear  was  bruised  during  the  forcible  feeding,  yet  the 
patient  was  frequently  engaged  in  fights  with  other  patients  at  this 
time,  when  she  was  liable  to  receive  blows  upon  the  ear.  There  was 
no  treatment,  and  the  tumor  passed  into  a  chronic  stage,  which  escaped 
observation  until  September,  18cS3,  when  serum  was  observed  to  ooze 
from  an  opening  in  the  outer  surface  of  the  auricle  just  above  the 
ooncha.  This  opening  was  enlarged  and  the  cavity  syringed  out  with 
a  solution  of  carbolic  acid  with  no  result.  On  October  19th,  the  sac 
was  laid  freely  open  by  the  author,  cleansed  of  the  blood  and  other 
contents,  and  the  walls  thoroughly  painted  with  Churchill's  solution 
of  iodine.  Notwithstanding  the  employment  of  such  pressure  as 
was  found  to  be  practicable,  the  parts  healed  up  again,  leaving  a 
small  sinus  as  before.  Subsequently  the  operation  was  tried  three 
different  times,  but  without  avail. 

November  23d  — A  slight  sero-sanguinolent  discharge  remaining, 
it  was  concluded  to  try  to  obliterate  the  tumor  by  scraping  its  walls 
with  a  cutting  scraper.  The  walls  of  the  sac,  however,  which  proved 
to  be  very  large,  consisted  of  broken-up  and  shrivelled  cartilage,  pre- 
senting rough  and  uneven  surfaces.  A  partly  detached  plate  of  car- 
tilage was  found  lying  on  the  outer  wall,  and  the  edge  of  the  superior 
portion  of  the  helix  could  be  felt.  There  was  a  deficiency  in  the  car- 
tilage composing  the  inner  wall  of  the  sac.  It  was  evident  that  the 
irregularities  of  the  walls  had  prevented  adhesions  of  the  surfaces 
from  taking  place. 

Operation. — With  a  small  sharp  scoop  every  portion  of  the  secreting 
surface  was  destroyed,  considerable  broken-down  tissue  being  brought 
away  by  the  instrument.  The  oozing  of  blood  was  quite  profuse  for 
a  time.  The  parts  were  thoroughly  cleansed  with  hot  water,  and 
pressure  established  by  bandaging  the  padded  ear  firmly  to  the  side 
of  the  head.  No  anaesthetic  was  employed.  The  parts  healed  kindly, 
pressure  was  maintained  for  some  time  afterward.  After  the  first 
week  there  seemed  to  be  some  improvement,  but  when  the  patient 
was  seen  on  December  22d,  the  cure  was  incomplete.  (It  is  very 
evident  that  union  could  only  be  obtained  between  the  walls  of  the  sac 
in  this  case  by  dissecting  out  the  irregular  and  detached  masses  of 
cartilage  which  prevent  them  coming  together). 


142 


OTHiEMATOMA. 


Case  IV. — Michael  F ,  35  years  of  age;  married;  intemperate; 

entered  New  York  City  Asylum  for  the  insane,  with  dementia,  1872. 
The  accompanying  cut  is  an  excellent  likeness  of  this  patient. 

The  eyebrows  have  almost  disappeared  from  constant  rubbing;  tries 
to  rub  his  eyes  out.  November  24th,  1883,  haematoma  of  the  right 
pinna  observed.     Continually  rubs  side  of  head  with  stones  and  beats 


Fig.  21. 


himself.  November  25th,  the  tumor  on  inner  surface  of  auricle  was 
incised.  .  .  . 

When  the  author  saw  this  patient  on  November  27th,  the  right 
auricle  was  thickened,  the'outlines  of  the  outer  surface  being  almost 
obliterated.  A  large  fluctuating  abscess  occupied  the  lower  half  of 
the  inner  surface  of  the  pinna,  and  extended  downward,  spreading 
out  over  the  mastoid  process  and  involving  the  lobule  (see  Fig.  22). 

It  had  been  treated  by  applications  of  iced  water.  An  incision, 
about  half  an  inch  long,  was  made  into  the  lower  part  of  the  abscess, 
evacuating  about  a  fluid  ounce  of  pus. 

It  would  seem  that  the  post-aural  abscess,  although  consecutive  to 
the  othaematoma,  was  due  to  the  constant  bruising  of  the  parts  by  the 
patient  himself.     The  othaematomatous  tumor  on  the  exterior  surface 


OTHEMATOMA.  143" 

of  the  auricle  probably  gave  rise  to  unusual  vascularity  in  the  whole 
organ,  and  there  may  have  been  an  opening  in  the  cartilage  permit- 
ting the  passage  of  the  contents  of  the  cyst  into  the  connective  tissue 
behind  the  ear.  but  there  was  no  evidence  of  any  separation  of  the 
perichondrium  from  the  cartilage  on  its  inner  surface,  and  the  con- 


FlG.  22. 

tents  of  the  abscess  apparently  contained  no  serum.  There  was  no 
history  as  to  the  exact  duration  of  the  othaematoma. 

Case  V. — Ignatius  J ,   aged  40,    was   admitted  to  the  New 

York  City  Asylum  for  the  Insane,  August  18th,  1883,  with  dementia. 
A  slight  haematoma  was  observed  to  be  developing  in  the  left  ear, 
October  28th.  When  examined  by  the  author,  the  concha  was  much 
thickened  as  far  as  the  meatus,  in  fact  almost  obliterated.  No  sac- 
culated fluid  was  ever  discovered. 

The  haematoma  came  on  at  the  stage  of  mitigation  of  chronic 
meningitis,  which  fact  is  considered  noteworthy.  Its  benign  condi- 
tion rendered  treatment  unnecessary. 

Case  VI. — Joseph  B- ,  admitted  to  the  New  York  City  Asylum 

for  the  Insane,  May,  1883,  was  noisy  and  violent.  About  June  30th, 
two  haematomas  of  considerable  size  developed.  The  left  haematoma 
ruptured  about  July  9th.     A  month  later,  the  left  ear  began  to  shrivel 


144: 


OTHEMATOMA. 


up,  reabsorption  of  the  effused  fluid  taking  place.  When  the  author 
saw  this  patient,  the  ears  had  a  shrunken  appearance.  Fig.  23  shows 
the  deformity  of  the  left  ear. 

Case  VII. — Hugh  S ,  aged  43,  admitted   to  the   New   York 

City  Asylum  for  the  Insane,  March  1st,  1881.  He  had  hallucinations, 
was  hard  to  control,  and  tore  his  clothing,  etc.,  up  to  the  time  the 


FiQ.  28. 


Fig.  34. 


writer  saw  him,  in  January,  1884.  Fig.  24  shows  the  condition  of  the 
left  ear.'  The  history  gives  no  account  of  the  time  of  its  appearance 
or  progress. 

Case  VIII.— Eliza ,  aged  30,  admitted  September  30th,  1882, 

with  acute  melancholia.  On  December  23d,  slight  redness  and  swell- 
ing of  the  fossae  of  the  left  auricle  was  observed,  the  inner  surface  of 
the  organ  being  unaffected.  On  December  24th  the  concha  was  in- 
vaded, occluding  the  meatus,  and  the  ear  was  poulticed.  The  tumor 
increased  in  size  until  the  28th,  when  it  was  as  large  as  a  hen's  egg. 
It  remained  stationary,  the  poulticing  being  continued  until  the 
30th  when  it  was  laid  freely  open  by  a  horizontal  incision,  evacuat- 
ing a  blood-clot  and  bloody  serum.     The  cavity,  which  was  about  one 


*  The  author  is  indebted  to  Dr.  Trautman  for  the  excellent  photographs 
from  which  Figs.  21,  22,  23,  and  24  were  taken. 


OTHEMATOMA.  145 

and  a  half  inches  long  by  one-half  inch  wide,  was  syringed  out  with 
carbolized  water  and  afterward  packed  with  oakum  and  balsam  of 
Peru.  December  31st  a  compress  was  applied.  The  outer  surface  of 
the  auricle  now  presented  a  smooth,  convex  surface  ;  the  topographical 
outlines  of  the  cartilage  were  absent,  the  concha  and  lobule  even 
being  indisguishable.  The  tragus  was  unaffected,  but  was  in  contact 
with  the  tumor.  The  swollen  tissues  were  of  a  dark  purple  color. 
From  the  wound  made  by  the  incision  there  was  constant  and  profuse 
oozing  of  sero-sanguinolent  fluid,  which  trickled  down  the  neck  of  the 
patient.  The  arms  of  the  patient  had  to  be  confined  to  prevent  fur- 
ther infliction  of  self-injury  to  the  ear.  Subsequently  an  abscess 
formed  on  the  posterior  surface  of  the  auricle,  and  ruptured  in  that 
situation,  the  contents  discharging  from  both  anterior  and  posterior 
wounds.  Gradual  healing  of  the  parts  took  place  during  January, 
the  walls  of  the  cyst  uniting  and  the  abscess  healing  by  granulation. 
February  24th,  ear  completely  healed.  An  examination  in  May  showed 
the  existence  of  considerable  thickening  in  the  superior  portion  of 
the  auricle,  with  partial  obliteration  of  the  concha.  The  organ  is  not 
reduced  in  size  apparently,  although  it  has  a  shrivelled  look,  the  out- 
lines of  the  antihelix  being  distorted.  The  integument  was  not 
markedly  adherent,  and  its  color  normal. 

Case   IX. — Mrs.  Barbara   K ,  aged   40,  admitted  July,  1883, 

with  acute  melancholia.  Has  delusion  that  devils  are  in  her  head 
and  hallucinations  of  hearing.  To  prevent  devils  "  crawling  "  into 
her  ears  and  to  exclude  annoying  voices,  she  thrusts  foreign  bodies, 
such  as  pebbles,  rags,  and  the  like,  into  her  ears.  On  August  6th, 
the  whole  right  exterior  ear  was  observed  to  be  intensely  hyperaemic, 
but  not  thickened.  The  meatus  externus,  howeveu,  was  occluded  by 
swelling  of  its  walls,  and  a  little  pus  was  found  on  syringing  out  the 
canal.  On  the  8th,  the  auricle  was  much  more  swollen,  the  markings 
becoming  indistinct.  Hot  applications  were  made,  and  on  the  9th 
pus  flowed  from  the  meatus  freely.  On  the  13th  it  was  observed  that 
considerable  purulent  discharge  was  escaping  from  over  the  superior- 
margin  of  the  concha.  Hot  fomentations  were  employed,  and  the 
rupture  healed  by  granulation  about  August  28th,  leaving  the  cartila- 
ginous portion  of  the  external  auditory  canal  occluded,  the  walls  being 
in  contact.  The  concha  and  fossa  of  the  helix  were  obliterated  and 
the  tissues  indurated  ;  the  auricle  is  greatly  thickened  and  shrivelled. 
Hearing  is  unimpaired  on  this  (right)  side. 

It  will  be  observed  that  in  two  of  the  above  cases  there  were  com- 
plications attended  with  suppuration;  in  one  of  them — Case  VIII. — 
this  was  due  probably  to  contusions  of  the  parts  during  the  progress 
of  the  othasmatoma,  and  in  the  other  case  (IX.)  the  othaematoma. 
seems  to  have  been  caused  by  trauma  and  suppurative  inflammation 
in  the  external  auditory  canal. 

Case  X. — Female,  aged  32.     Has  dementia,  and  is  violent.     On 
October  19th,  1882,  the  left  auricle  suddenly  became  the  seat  of  a 
10 


146  OTH.EMATOMA. 

haematomatous  tumor  the  size  of  a  pigeon's  egg  ;  it  was  of  a  dark 
purple  color,  and  was  situated  on  the  outer  surface.  The  swelling 
impinges  on  the  concha,  and  occludes  the  external  auditory  meatus. 
Its  progress  was  at  first  slow,  remaining  stationary  for  six  weeks, 
when  it  again  commenced  to  gradually  increase  in  size  without  active 
inflammatory  symptoms.  There  was  fluctuation,  but  no  pain  ;  the 
skin  was  thickened,  movable,  and  very  much  less  discolored.  Outline 
of  helix  remains,  but  antihelix  and  fossa  obliterated  ;  meatus  more 
free.  The  posterior  surface  of  the  auricle  was  unaffected.  Self-in- 
flicted injury,  due  to  the  long-continued  practice  of  violently  pressing 
the  ears  with  her  hands,  had  doubtlessly  given  rise  to  the  trouble. 
She  always  has  numerous  marks  on  the'  chest  and  elsewhere  from 
self-inflicted  injuries.  The  case  progressed  favorably  from  this  time 
on,  without  any  treatment,  spontaneous  recovery  finally  taking 
place. 

Case  XI. — Patient,  a  professional  gymnast,  aged  35  years,  had  re- 
ceived, three  weeks  previously,  a  "  cross-counter  "  blow  upon  the  left 
ear  with  a  gloved  hand.  This  gave  rise  to  no  pain,  but,  tw^o  weeks 
later,  the  ear  was  again  contused  by  a  powerful  blow  from  the  foot  of 
a  person  in  training.  The  latter  injury  even  caused  no  pain  at  the 
time,  but  twenty-four  hours  later,  after  exercising  for  two  hours,  the 
auricle  was  observed  to  be  unusually  warm  and  swollen. 

The  writer  found,  on  examination,  a  tumor  slightly  pinkish  in 
color,  seated  at  the  fossa  of  the  antihelix;  it  had  spread  itself  almost 
equally  in  all  directions,  encroaching  considerably  on  the  concha.  It 
had  partially  refilled  again,  was  "doughy"  to  the  touch,  but  not  ten- 
der. Hearing  was  unaffected.  Half  a  drachm  of  straw-colored  fluid 
was  removed  by  aspiration,  and  the  tumor  was  painted  over  with  col- 
lodion, the  patient  feeling  the  pressure.  Small  doses  of  tincture  of 
aconite  were  ordered,  and  rest  was  advised.  The  next  day  the  tumor 
was  softer,  aspiration  was  repeated,  and  the  treatment  continued, 
with  the  addition  of  compression  by  means  of  padding  of  cotton- wool 
and  bandaging.  Tumor  seemed  to  be  in  static  quo,  effusion  having 
probably  ceased  and  reabsorption  commenced. 

It  was  found  that  the  collodion  contracting  upon  the  tumor  had 
made  it  quite  tense  and  blanched  in  appearance,  but  that  with  each 
pulsation  of  the  anterior  auricular  artery  (which  supplies  the  anterior 
surface  of  the  auricle)  the  entrance  of  the  blood-supply  was  charac- 
terized by  a  glow  of  deep-red  coloring,  ivhile  the  subsidence  which  suc- 
ceeded to  each  distention  ivas  accompanied  by  blanching  of  the  parts. 
The  pulsations  of  the  temporal  artery  were  visible  above  and  in  front 
of  the  tragus. 

Treatment  continued,  excepting  the  aspiration.  A  few  days  later 
massage  cautiously  commenced.  Progress  was  now  uninterrupted, 
the  massage  being  gradually  increased  in  force  and  frequency.  The 
collodion  during  the  treatment  was  peeled  off  daily,  and  a  fresh  coat- 
ing applied.  Scarcely  any  deformity  was  observable  at  this  time,  but 
the  concha  was  still  smaller  than  normal,  and  the  outlines  of  the  an- 
tihelix were  not  sharply  outlined.  The  patient,  when  discharged, 
was  directed  to  continue  the  massage  for  some  time. 


OTHEMATOMA.  .  147 

Case  XII. — The  othaematoma  was  evidently  caused  in  this  case 
by  the  patient  ha,Ymg  folded  up  the  left  auricle  upon  itself  by  an  acci- 
dentalhloiv  with  his  own  hand  whileplaying  tvith  his  child  a  short  time 
before.  A  small  cystic  swelling  made  its  appearance  on  the  upper  and 
outer  aspect  of  the  auricle  soon  after.  The  patient  was  obliged  to 
undertake  a  long  journey  shortly  after  coming  under  the  care  of  the 
writer,  on  which  occasion  he  contracted  a  severe  cold.  This  was  fol- 
lowed by  fever,  pains  in  the  head,  and  an  extension  of  the  inflamma- 
tion itself  to  the  parts  above  the  ear;  also  by  effusion,  both  in  front 
of  and  back  of  the  cartilage.  The  patient  was  confined  many  weeks 
to  his  house.  The  cyst  was  laid  open  by  a  long  incision,  the  wound 
being  packed  with  lint  soaked  in  carbolized  oil.  The  auricle  was  yet 
quite  tender  to  the  touch,  and  sensitive  to  draughts  of  air  even  some 
five  months  later,  although  the  parts  had  been  for  some  time  entirely 
healed.  The  author  saw  the  patient  about  three  years  after  this.  It 
was  found  then  that  the  auricle  was  considerably  deformed,  the  supe- 
rior portion  of  the  cartilage  being  much  contracted,  the  antihelix 
quite  obliterated.  It  was  evident  that  the  long  railway  journey,  the 
want  of  proper  rest,  and,  above  all,  the  cold  contracted,  made  a 
severe  case  out  of  what  would  probably  have  been  a  mild  one. 

Case  XIII. — Patient  came  for  treatment  with  a  small  sanguineous 
tumor  on  the  outer  aspect  of  the  left  auricle,  between  the  helix  and 
antihelix,  near  the  superior  border.  The  tumor  was  of  a  deep-red 
color,  and  slightly  painful  when  handled.  No  urgent  symptoms 
were  present,  and  no  subsequent  visit  was  made. 

Case  XIV. — Patient,  a  tailoress,  aged  27  years,  of  very  intemperate 
habits,  stated  that  one  month  ago  the  left  ear  was  violently  jerked  by 
her  husband,  and  that  the  next  morning  it  swelled  up,  and  was  of  a 
very  dark  purple  color.  A  day  or  two  afterward  the  husband  opened 
the  swollen  tissues  with  a  blade  of  his  pocket-knife.  This  operation 
increased  the  swelling,  and  a  few  days  afterward  a  "doctor^'  laid  the 
outer  aspect  of  the  tumor  open  with  a  lance.  The  cyst  now  became 
intensely  swollen,  and  was  as  large  as  the  patient's  "  fist."  The  hus- 
band then  came  home  again  in  a  drunken  state,  and  struck  her  on 
the  ear,  causing  a  discharge  of  its  contents  to  take  place  from  the 
superior  surface  of  the  cyst.  Flax-seed  poultices  were  constantly 
applied  to  the  ear  during  the  attack.  The  posterior  surface  and  the 
lobule  were  at  no  time  affected.  From  the  first  the  ear  was  for  a 
while  painful.  The  tumor  was  hard,  about  one  inch  in  thickness, 
and  from  above  downward  one  and  three-quarters  of  an  inch  in 
length.  It  was  oval  in  shape,  its  outer  surface  corrugated,  and  some- 
what resembling  an  almond  that  has  been  divested  of  its  outer  cor- 
tex. It  was  not  sensitive  to  the  touch,  and  iji  color  was  dai'k  red, 
like  the  rest  of  the  face  and  neck.  Hearing  is  unaffected.  The  ears 
naturally  small.  Fig.  25  shows  the  affected  ear's  appearance  at  the 
time  of  her  first  visit.  The  local  treatment  was  expectant;  internally 
the  tincture  of  aconite  root  was  ordered  in  small  and  frequently  re- 
peated doses.     Rest  and  better  personal  hygiene  recommended.  J 


148 


OTHEMATOMA. 


Fig.  25. 


Case  XV. — Patient  came  with  the  statement  that  two  months  pre- 
viously he  had  received  an  injury  to  the  right  ear  by  being  jammed 
against  a  door  while  in  a  state  of  intoxication.  Twelve  hours  after- 
ward he  experienced  soreness  of  the  auricle,  which  was  limited  to  the 
upper  part  of  the  helix;  this  continued  without  observable  swelling 
for  six  weeks.  Two  weeks  ago  he  noticed  that  the  outer  aspect  of  the 
ear  was  "  puffed  out,"  and  two  days  later  an  incision  was  made  into 
it  by  a  physician  to  whom  he  went  at  the  time;  there  was  an  escape 
of  sero-sangu indent  fluid,  but  by  the  next  morning  the  incision  had 
closed,  and  the  cyst  had  refilled.  Two  days  later  another  physicip.n 
was  seen,  who  cut  the  part  open  with  scissors,  and  on  the  following 
day  increased  the  size  of  the  opening  by  making  a  crucial  incision. 
It  seems  that  these  measures  were  not  sufficient  to  prevent  the  filling 


OTHEMATOMA.  149 

and  distention  of  the  sac,  and  that  five  days  before  a  "piece  was  cut 
out/'  and  the  cavity  then  packed  with  oakum.  Subsequently  efforts 
were  made  to  bandage  the  ear  to  the  head.  The  oakum  was  allowed 
to  remain  for  three  days,  and  the  ear  was  then  poulticed.  When  the 
writer  first  saw  the  case  the  auricle  was  very  much  enlarged,  had  an 
angry  look,  and  was  of  a  purplish  color.  (See  Fig.  26.)  It  was  not 
very  tender  to  the  touch.  Hearing  was  unaffected.  It  was  very  evi- 
dent tluit  the  patient  was  in  a  state  of  chronic  alcoholism,  and  he  was 
told  that  treatment  would  be  almost  unavailing  unless  he  left  off  the 
use  of  stimulants.  The  fluid  which  had  again  accumulated  was  now 
removed  by  aspiration,  and  it  was  determined  to  try  pressure  so  soon 
as  the  necessary  dressings  could  be  borne.  For  ten  days  the  improve- 
ment was  uninterrupted;  the  fluid  removed  at  each  visit  was  found 
to  be  more  and  more  thin  and  pale,  and  the  quantity  less  and  less. 


Fig.  26. 

The  ear  was  not  so  angry  in  appearance,  the  outlines  of  the  helix  be- 
gan to  show  themselves,  and  the  sac  diminished  in  size.  The  tissues 
were,  however,  considerably  inflltrated. 

The  patient  now  resumed  his  intemperate  habits,  with  the  result  of 
very  much  exasperating  the  condition  of  the  ear,  the  organ  becoming 
much  worse  after  each  debauch.  Being  unable  to  improve  his  habits 
in  this  regard,  the  treatment  was  finally  suspended  before  a  cure  was 
accomplished. 

Case  XVI. — Patient  had  his  auricle  twisted  by  another  boy  in  a 
fight,  a  week  before  coming  under  the  observation  of  the  author.  No 
pain  or  swelling  of  tiie  auricle  was  remarked  until  four  days  after  the 
injury,  when  a  '*  throbbing  pain,"  and  some  increase  in  the  size  of 
the  auricle,  were  felt.  There  was  found,  on  examination,  a  swelling, 
about  the  size  of  a  Lima  bean  situated  in  the  triangular  fossa  of  the 
antihelix,  on  the  outer  surface  of  the  right  auricle.     The  inner  surface 


150  OTHEMATOMA. 

was  iinchaTiged.  Both  auricles  were  naturally  large  and  loosely  attached 
to  the  head.  The  tumor  was  tense  and  at  first  of  a  purplish  color.  At 
the  beginning  the  tumor  was  aspirated  and  a  few  drops  of  blood  were 
removed  ;  by  means  of  pressure  the  contents  were  almost  entirely 
evacuated,  leaving  it  collapsed.  Under  treatment  with  local  applica- 
tions of  collodion,  at  first  almost  daily,  pressure-bandage  and  after- 
wards massage,  the  auricle  resumed  its  normal  condition  in  about 
seven  weeks. 

Case  XVII, — Chinaman,  who  stated  that  he  had  experienced  pain 
in  the  upper  part  of  the  right  auricle  some  three  weeks  before.  The 
auricle  also  swelled  and  was  tender  to  the  touch.  The  swelling  had 
increased  steadily  ever  since.  On  examination  it  was  found  that  the 
fossa  of  the  helix  and  antihelix  of  the  right  ear  were  swollen  and 
fluctuating.  The  swelling  extended  from  the  upper  margin  of  the 
auricle  to  the  spine  of  the  helix.  Posterior  surface  of  auricle  not  in- 
volved. The  habits  of  the  patient  were  temperate  and  there  was  no 
history  of  trauma.  He  was  accustomed,  however,  to  sleeping  on  a 
board,  and  it  is  very  probable  that  the  auricle  may  have  become  con- 
tused by  contact  with  this  hard  surface.  Treatment  was  the  same  as 
in  the  other  cases,  and  when  last  seen,  the  auricle  was  nearly  normal 
in  appearance. 

Case  XVIII. — A  youth,  aged  19  years,  came  to  the  Infirmary  on 
account  of  a  purulent  affection  of  the  ear.  On  examination  it  was 
found  that  the  concha  of  the  right  auricle  was  much  deformed.  The 
cartilage  of  this  region  was  irregularly  thickened,  having  a  nodular 
feel.  The  skin  was  firmly  adherent  to  both  the  anterior  and  posterior 
surfaces.  The  rest  of  the  auricle  was  not  involved.  This  deformity 
was  caused  by  a  twist  of  the  auricle  by  the  mother  when  he  was  a 
child.  Immediately  after  the  injury,  the  parts  were  swollen  and  a  soft 
fluctuating  tumor  soon  formed.  The  contraction  of  the  perichondrium 
during  the  healing  process  had  caused  the  deformity. 

From  the  numerous  cases  of  othaematoma  occurring  among  boxers 
which  were  examined  by  the  writer,  the  following  two  cases  were  se- 
lected as  good  illustrations  : 

Case  XIX. — John  F ,  29  years  of  age,  intemperate,  has  been 

a  boxer  for  ten  years.  Nine  years  ago  he  received  a  blow  from  '*  cross 
counter  "  upon  left  ear.  The  auricle  became  swollen,  red,  and  tender, 
the  pain  extending  all  about  the  ear  and  down  the  neck.  The  tumor 
never  opened,  and  became  indurated  in  about  one  month.  "While  the 
tumor  remained  "soft'^  it  was  repeatedly  struck  in  boxing  without 
other  effect  than  slightly  increasing  the  local  sensitiveness.  After  re- 
covery, which  took  place  without  treatment,  constant  bruising  failed 
to  produce  a  recurrence  of  the  tumor.  The  outer  surface  of  the  left 
auricle  is  irregularly  nodular — the  fossae  being  obliterated  and  the 
outlines  of  the  ear  completely  destroyed,  with  the  exception  of  the 
helix,  which  was  not  affected.  The  auricle  is  about  three-fourths  of 
an  inch  thick,  and.  the  concha  is  reduced  in  size,  due  to  thickening 


OTHEMATOMA. 


151 


of  autitragus.     The  posterior  surface  is  normal, 
charged,  and  hearing  is  good. 


The  ear  never  dis- 


Case  XX. — Thomas  A ,  26  years  of  age,  has  been  a  boxer  for 

many  years.  Eeceived  a  blow  upon  left  ear  from  "cross  counter'* 
three  years  ago,  producing  a  soft,  tender  swelling  of  the  ear,  and 
much  pain  in  the  organ  and  side  of  the  head  and  down  the  neck. 
There  was  also  a  *'numb"  feeling,  and  autophonia,  which  remains. 
Hot  milk  and  slippery-elm  poultices  were  applied.  The  tumor  was 
at  first  purple  in  color,  afterward  it  became  red.  It  remained  "soft" 
for  a  period  of  five  months,  during  which  time  it  was  frequently  rup- 
tured by  blows.  Afterward  it  became  hard  and  deformed.  The  au- 
ricle is  smooth,  all  of  the  markings  being  obliterated  except  the 
anterior  portion  of  the  helix  which  is  normal,  and  is  fully  one  inch 
in  thickness.  The  pinna  seems  folded  upon  itself  from  above  down- 
ward. The  concha  is  impinged  npon  from  behind,  leaving  a  mere 
slit  in  front  of  the  meatus  externus.  There  is  some  deafness  in  the 
left  ear,  due  doubtlessly  to  the  blow  upon  the  organ.  The  resulting 
deformity  is  similar  to  that  shown  in  Fig.  24. 

The  occurrence  of  othaematoma  in  the  mentally  sane  is  uncommon; 
a  glance  at  the  literature  of  the  subject  shows  that  it  has  been  com- 
paratively seldom  the  subject  of  observation  among  foreign  writers, 
while  American  authors  have  thus  far  reported  only  some  ten  cases. ^ 

The  following  table,  showing  several  important  points  in  the 
author's  nine  cases  among  the  mentally  sane,  it  is  hoped  will  not  be 
without  interest. 


si 

^ 

^ 

43 

M.  j 

35 

M. 

43 

M. 

40 

M. 

27 

F. 

25 

M. 

12i 

M. 

44 

M. 

5(?) 

M.  1 

Occupation. 


Ear  affected. 


Negro-minstrel    Right. 

Gymnast  Left.... 

Lawyer |Left 

Packer Left 

Tailoreas [Left. . .. 

Merchant jKight... 

Schoolboy Right... 

Laundryinan...  .Right... 
Right... 


Habits. 


Temperate... 
Temperate. . . 
Temperate... 
Temperate... 
Intemperate. 
Intemperate. 


Intemperate 


Cause. 


Trauma. 

Trauma. 

Trauma. 

Trauma  (?). 

Trauma. 

Trauma. 

Trauma. 

Trauma  (?). 

Trauma. 


1  Vide  C.  J.  Blake:  Statistical  Rept.  of  1,632  Cases  of  Diseases  of  the  Ear, 
treated  at  the  Mass.  Ch.  Eye  and  Ear  Inf.  during  the  year  1872  :  one  case  of 
othaematoma — A.  J.  Otol.,  vol.  iii.,  pp.  193-196.  H.  Knapp  :  Arch,  Otol.,  vol. 
ix.,  pp.  195-203.  Roosa  :  Trans.  Am.  Otol.  Soc,'>  vol.  i.,  pp.  23-127.  Kipp  : 
Trans.  A.  O.  Soc,  vol.  i.,  p.  79.  Poraeroy  :  Ibid.,  vol.  ii.,  pp.  83-86.  Buck  : 
Diagnosis  and  Treat,  of  Ear  Diseases.  Pooley  :  Medical  Record,  vol.  xix., 
pp.  313-315. 


152  GUNSHOT   WOUNDS. 

From  the  foregoiug  it  will  be  observed  that  the  cause  of  the  lesion 
in  seven  cases  was  traumatic  ;  in  two  cases  the  history  in  this  respect 
was  incomplete.  Eight  of  the  patients  were  males,  only  one  a  fe- 
male. The  hearing,  as  will  have  been  seen  in  the  histories  given,  was 
unimpaired  in  any  of  these  patients. 

OTHEMATOMA    IN    THE    LOWER    ANIMALS. 

This  form  of  disease  is  said  to  affect  dogs,  an  account  of  its  occur- 
rence in  whom  has  been  given  by  Mr.  S.  Ogier  Ward.'  Wilde  states 
that  he  observed  the  trouble  in  a  valuable  pointer.  The  writer  has 
never  seen  a  well-defined  case  of  othaematoma  in  a  dog,  unless  isolated 
hard  lumps  in  the  pendent  portion  of  the  organ  be  such.  It  would 
seem  that  some  shrinking  of  the  auricle  would  be  produced  by  peri- 
chondritis rather  than  the  "lumps"  alluded  to  by  writers. 

The  cat,  it  would  seem,  is  liable  to  othaematoma,  an  example  of 
which  was  shown  to  the  author.  The  animal  (a  male)  which  was  the 
subject  of  the  trouble  was  of  the  Angora  strain,  and  was  one  year  and 
a  half  old.  He  was  a  fine  example  of  the  kind,  and,  perhaps  owing 
to  high  breeding,  very  excitable,  not  to  say  wild  and  uncontrollable. 

Over  two  weeks  before  the  entire  inner  surface  of  the  left  auricle 
had  been  swollen  out,  the  affected  organ  forming  a  long,  pointed 
tumor.  The  effusion  was  gradually  reabsorbed,  and  when  the  writer 
examined  the  ear  afterward,  it  was  smaller  than  the  right  one,  and 
somewhat  thickened  and  shrivelled.  The  presence  of  some  cutaneous 
trouble  in  the  post-auricular  region  and  over  the  vertex  was  noted. 
The  auricle  had  assumed  its  natural  color.  Subsequently  to  the  above, 
the  right  auricle  became  affected  in  the  same  way  the  left  had  been. 
There  was  no  evidence  of  the  auricle  having  been  scratched. 

The  writer  has  frequently  examined  the  ears  of  pugilistic  cats  with 
ears  deformed  by  lacerations  produced  by  biting  and  scratching,  but 
has  never  before  met  with  an  example  where  deformity  characteristic 
of  perichondritis  existed. 

GUNSHOT  WOUNDS. 

The  number  of  gunshot  wounds  of  the  ear  occurring  in  modern 
warfare  is  very  great.  It  is  stated  '  that  the  number  of  wounds 
of  the  head  from  all  causes,  in  the  Civil  War,  was  12,980;  of  the  face, 

*  Loc.  cit. 

'^  Medical  and  Surgical  History  of  the  War  of  the  Rebellion.  Part  First. 
Surgical  Volume. 


GUNSHOT   WOUNDS.  153 

9,815;  and  gunshot  wounds  of  the  neck,  4,895.  The  greater  number 
of  the  head  and  face  wounds  were,  of  course,  made  by  musket  balls. 

Out  of  this  large  number  of  casualties,  viz.,  27,690,  examples  of 
many  especially  interesting  cases  were  selected  by  the  editor,  the  late 
Oeo.  A.  Otis,  then  Assistant  Surgeon  U.  S.  A.,  from  the  records  of 
the  Surgeon-General's  office  for  publication  in  the  great  work  men- 
tioned. 

An  examination  of  these  selected  cases  by  the  writer,  for  the  pur- 
pose of  ascertaining  the  frequency  and  extent  of  aural  injury  either 
direct  or  in  cases  of  severe  wounds  in  the  immediate  vicinity  of  the 
ear,  shows  that  this  organ  is  seldom  more  than  incidentally  or  vaguely 
alluded  to  even,  and  that  no  attempts  whatever,  worthy  of  mention,  were 
made  to  differentiate  complicated  wounds  of  the  organ.  In  reviewing 
the  literature  offered  in  the  national  work  mentioned,  with  the  object 
stated  in  view,  the  enormous  labor  of  classification,  it  should  be  stated, 
seems  to  have  been  done  with  great  fidelity  and  industry,  and,  when 
the  material  at  hand  is  considered,  it  should  also  be  said,  satisfactorily. 
On  looking  back,  moreover,  from  the  present  point  of  view  to  the 
period  when  so  many  medical  men  went  into  the  field  with  scarcely 
any  preparation  for  special  work,  it  must  be  borne  in  mind  that  too 
close  scrutiny  of  the  results  is  not  fairly  admissible.  In  the  exami- 
nation of  this  vast  store-house  of  military  surgical  history  one  cannot 
but  feel,  however,  that  by  far  the  greater  part  of  the  surgical  history 
of  the  late  war  was  lost  because  of  the  utter  impossibility  of  the 
proper  records  being  kept  by  the  medical  officers  in  the  field,  and  in 
consequence  of  their  inexperience  in  many  of  the  special  departments 
of  surgery.  The  mass  of  material  which  has  been  placed  at  our  dis- 
posal was  of  so  complex  a  character  that  precise  classification  was 
found  to  be  impossible.  There  could  have  been  but  little  experi- 
ence at  best  in  military  aural  surgery,  since  otology  was  almost  in  its 
infancy  when  the  war  began  in  1861. 

However  much,  then,  the  otologist  of  to-day  may  regret  that 
wounds  and  injuries  of  the  ear  were  not  more  frequently  reported  in 
detail  by  the  military  surgeons  who  could  have  observed  them,  the 
facts  just  stated  seem  to  explain  sufficiently  the  meagreness  of  the 
results.  Undoubtedly  the  statistics  bearing  on  this  subject  would  have 
been  much  fuller  had  not  a  large  number  of  injuries,  including  many 
of  the  ears,  been  overlooked,'  for  the  temporal  bone  or  its  exterior 
attachments  are  scarcely  ever  seriously  injured  without  impairment 
of  the  hearing  organ   in   some  degree.     A  careful  search,  however, 

'  Wounded  prisoners  and  absentees  would  double  the  number. 


154  GUNSHOT    WOUNDS. 

among  the  various  abstracts  published  has  not  been  without  profit, 
inasmuch  as  it  has  been  thus  found  that  wounds  and  injuries  of  the 
head,  face,  and  neck  give  rise  very  frequently  to  impairment  of  hearing. 
The  subject,  therefore,  assumes  much  greater  importance  than  it 
would  obtain  from  a  mere  statistical  standpoint,  and  especially  so  if 
the  maiming  and  deformity  are  considered,  since  both  justice  and 
humanity  demand  that  the  deserving  soldier  should  not  be  prevented 
from  obtaining  a  proper  pension  on  account  of  any  neglect  in  medical 
examinations  for  either  discharge  from  service  or  in  applying  for  a 
pension. 

The  valuable  contribution  to  military  surgery,  to  which  allusion  has 
heen  made,  gives  only  sixteen  cases  of  ear  injury  from  gunshot  con- 
tusions of  the  skull.  These  have  heen  classified,  somewhat  indefi- 
nitely, under  the  general  head  of  "deafness,"  and  embrace  all  the 
injuries  of  this  kind  that  could  be  collected  from  the  reports  in  the 
Surgeon-GeneraFs  office. 

It  was  found  that  none  of  these  cases  were  fatal,  and  it  is,  further- 
more, an  interesting  fact  that  in  some  instances  the  missile  entered 
at  a  point  remote  from  the  ear,  but  involved  the  organ  in  its  course. 
Dr.  Otis,  unfortunately,  found  no  time  to  arrange  the  material  in  the 
Surgeon- General's  office  so  as  to  more  completely  bring  out  all  the 
points  of  interest  in  connection  with  aural  complications;  indeed,  the 
painstaking  efforts  made  to  classify  gunshot  injuries,  in  a  more  general 
way  even,  was  a  work  of  great  labor.  A  few  remarks  were  made, 
however,  under  ^'  wounds  of  the  ear,"  which  will  be  considered  further 
on. 

A  careful  collation  of  the  material  scattered  throughout  the  surgi- 
cal volume,  in  various  sections,  brings  to  light  some  interesting  cases. 
The  following  is  found  under  "  Disabilities  Following  Gunshot  Frac- 
tures "  (also  alluded  to  in  "  Wounds  of  the  Ear  "). 

Lieut.  Wm.  S.  Simms,  82d  N".  Y.  Volunteers,  was  wounded  at  the 
Battle  of  the  Wilderness,  Va.,  May  6th,  1864,  by  a  conoidal  musket 
ball,  which  penetrated  the  left  mastoid  process,  leaving  a  small  ex- 
ternal opening,  and  injuring,  it  is  stated,  the  "  internal "  ear.  "  The 
missile,  which  was  removed  on  the  field,  had  become  elongated. '* 
He  was  speechless  for  ten  days,  and  his  intellect  was  subsequently 
found  to  be  greatly  impaired.  On  partial  recovery,  about  two  months 
after  the  injury,  he  was  transferred  to  the  59th  N.  Y.  Volunteers  as 
major,  and  was  mustered  out  of  service  one  year  later,  the  wound 
being  still  open,  the  left  side  of  the  face  partially  paralyzed,  and  with 
partial  hemiplegia  of  the  right  side.  In  1871  he  was  examined  by 
the  Pension  Board  in  New  York,  when  it  was  found  that  there  was 
a  large  opening  in  the  temporal  bone  "  one-half  an  inch  in  diameter 
and  two  and  one-half  inches  in  depth,  forward  and  inward,  and  con- 


GL'NSHOT   WOUXD8. 


155 


nectingwith  the  ear/'  The  facial  paralysis  and  hemiplegia  remained, 
and  deafness  was  said  to  be  complete.  It  was  believed  that  some  in- 
flammation of  the  brain  existed,  and  that  a  fatal  termination  was  to 
be  expected. 

Note. — The  writer  saw  Mr.  Simms,  who  has  resided  in  the  Bloom- 
ingdale  Asylum  for  some  time  past,  in  November,  1883.  He  is  now 
well-nourished,  but  owing  to  the  right  hemiplegia,  the  right  side  is 
much  smaller  than  the  left,  and  he  limps  in  walking.  The  facial 
paralysis  is  still  present,  but  gives  him  less  trouble  than  formerly. 
Mastication  can  be  performed  on  the  leftside  to  some  extent,  although 
the  teeth  on  both  sides  are  very  defective,  many  of  them  being  ab'- 


FiG.  27 


sent.  The  inability  to  close  the  left  eye  gives  him  but  little  trouble 
unless  dust  or  strong  draughts  of  air  strike  it.  He  has  been  able  to 
breathe  quite  well  through  the  left  naris  for  the  past  year  (previously 
it  was  collapsed).  He  has  no  pains  anywhere  excepting  in  the  right 
foot,  the  toes  of  which  are  in  a  state  of  contraction. 

Examination  of  Ears. — Right  ear,  large  external  auditory  canal. 
The  drum-head  is  greatly  retracted  over  the  short  process,  and  in 
consequence  has  numerous  folds,  a  result  of  defective  development. 
Hearing  in  this  ear  is  very  good. 

The  left  ear,  which  was  injured,  presents  the  following  appear- 
ances: Large  auditory  meatus.  There  is  an  oval  opening  (see  Fig. 
27)  about  one-half  an  inch  in  diameter,  just  behind  the  auricle,  its 


156  GUK8H0T   WOUNDS. 

lower  wall  a  little  above  the  floor  of  the  external  auditory  canal. 
Its  lumen  does  not  face  directly  inward,  but  rather  forward.  With 
reflected  light,  and  without  a  speculum,  a  large  pathological  cavity 
may  be  seen,  embracing  all  of  the  space  formerly  occupied  by  the 
pneumatic  cells  of  the  mastoid  and  the  tympanum.  This  cavity  is 
lined  throughout  by  a  whitish  dermoid  membrane  of  new  formation, 
excepting  at  the  roof,  where  there  is  still  some  inflammatory  action 
in  progress,  the  parts  being  covered  by  a  rather  thick  and  closely  ad- 
herent crust  of  inspissated  pus.  This  cavity,  measuring  forward 
from  the  opening  behind  the  ear,  is  about  one  inch  and  a  half 
deep,  which  brings  the  probe  within  a  line  or  two  of  the  carotid 
canal.  A  probe  passed  into  the  external  auditory  canal  and  across 
the  cavity  described  strikes  the  inner  wall  of  the  tympanum  at  the 
distance  of  one  inch  and  an  eighth. 

The  wound  of  entrance  was  small,  it  is  said,  and  the  ball  when  re- 
moved was  elongated.  In  reviewing  the  history  of  the  case,  it  would 
seem  probable  that  the  missile  had  become  elongated  before  its  en- 
trance by  coming  in  contact  with  some  object,  which  also  broke 
somewhat  the  force  of  impact,  since  any  resistance  offered  by  the 
cortex  of  the  mastoid  would  have  been  likely  to  flatten  out  the  ball. 
A  ball,  moreover,  of  unchanged  diameter  and  greater  momentum  at 
the  moment  of  its  initial  resistance  would  have  produced  much  more 
serious  consequences.  Judging  from  the  present  appearance  of  the 
parts,  the  missile  passed  through  the  upper  portion  of  the  pneumatic 
cells  of  the  mastoid,  and,  passing  along  forward  in  an  almost  hori- 
zontal direction,  carried  away  the  inner  extremity  of  the  external 
auditory  canal  on  its  outer  side,  and  scraped  the  inner  wall  of  the 
tympanum  on  the  inner  side  of  its  track.  In  wedging  itself  in  the 
narrow  bed  offered  by  the  parts  penetrated,  the  upper  surface  of 
the  ball  lifted  up  the  tegmen  tympani,  while  its  anterior  extremity 
almost  penetrated  the  carotid  canal.  The  transmitting  mechanism 
and  a  portion  of  the  facial  nerve  were,  of  course,  entirely  destroyed, 
unless,  indeed,  the  round  window  and  foot  plate  of  the  stapes  were 
left  in  a  mutilated  state.  The  carious  process,  in  the  mastoid  cells, 
as  sometimes  happens  in  purulent  inflammation  of  the  parts  conse- 
quent to  otitis  media,  must  have  gone  on  until  this  structure  was 
entirely  broken  down.  Minute  sequestra  came  away  until  two  years 
ago.  The  healing  process  has  been  going  on  here  for  the  past  nine- 
teen years,  almost  unaided  by  treatment  much  of  the  time.  The  pro- 
tective provisions  of  nature  here  prevented  the  destructive  processes 
from  breaking  through  the  walls  of  the  carotid  artery,  the  lateral 
sinus,  and  the  dura  mater  above  the  roof  of  the  tympanum.  The 
■crust  lying  upon  the  tegmen  was  lifted  up  by  a  probe,  exposing  a  thick 
pultaceous  mass  beneath.  This  the  writer' did  not  remove,  although 
the  thought  occurred  to  him  that  the  monthly  epileptic  attacks, 
with  very  decided  maniacal  symptoms,  to  which  the  patient  is  now 
subject,  might  in  some  measure  be  influenced  by  accumulations  of 
pus,  which  distend  the  parts  up  to  a  certain  point  before  finding  a 
vent  through  partial  detachment  of  the  crust.  Some  local  meningeal 
irritation  probably  remains  at  this  part.  The  patient  syringes  his 
ear  once  a  week,  and  with  an  ear-scoop  removes  any  accumulations 


GUJSSHOT    WOUNDS.  15T 

in  the  cavity  or  from  the  external  auditory  canal.  The  distressing^ 
tinnitus  aurium,  like  escaping  steam,  which  was  once  so  very  annoy- 
ing and  constant,  is  now  infrequent  and  scarcely  noticeable. 

There  seems  to  be  some  considerable  hearing  in  the  affected  ear,  the 
exact  amount  of  which,  however,  is  very  difficult  to  determine.  His 
memory  is  greatly  impaired. 

The  above  case  is  of  much  interest,  inasmuch  as  the  wounding  of 
the  mastoid  and  tympanum  gave  rise  to  a  condition  of  things  resem- 
bling cases  quite  often  seen  in  practice,  arising  from  neglected  mastoid 
disease  consequent  to  otitis  media. 

The  severe  shock  to  the  brain  and  fracture  of  the  tegmen  tympani 
at  the  moment  of  injury,  characterized  the  gunshot  wound  de- 
scribed. 

The  following  three  cases  are  not  classified  either  under  *' deaf- 
ness^' or  '^  wounds  of  the  ear,"  but  as  it  is  probable  that  the  hearing, 
was  affected  in  all  such  cases,  they  will  be  introduced  here. 


"  Capt.  Winfield  S.  Barr,  Co.  B.,  105th  Pennsylvania  Volunteers, 
aged  23  years,  was  wounded  in  an  engagement  before  Petersburg, 
Va.,  August  16th,  1864,  by  a  conoidal  ball,  vfhiok  fractured  the  mas- 
toid process  of  tlie  temporal  hone,  and  injured  the  base  of  the  occipi- 
tal." ''On  December  lih,  several  spicula  of  necrosed  hone  came 
aivay,  and  on  December  30th,  a  large  portion  of  the  mastoid  process 
was  removed."  ^  Captain  Barr  was  subsequently  mustered  out  of  ser- 
vice and  "  in  May,  1885,  he  was  a  pensioner,  and  his  disability  was 
rated  as  total  and  permanent." 

''Sergeant  Lyman  A.  P ,  Co.  D.,  8th  N.  Y.  Heavy  Artillery, 

aged  21  years,  who  was  wounded  at  Ream's  Station  on  August  2oth,. 
1864,  by  a  musket  ball,  which  entered  over  the  right  mastoid  process, 
injured  the  external  ear,  and  lodged  under  the  skin,  a  little  in  front 
of  the  auditory  foramen." '  "  The  ball  had  not  been  extracted,  and  no 
symptoms  attracted  special  attention  until  September  7th  when  Acting 
Assistant  Surgeon  A.  M.  Sherman,  in  charge  of  the  case,  observed  that 
the  right  parotid  gland  was  so  greatly  inflanied  that  the  patient  with 
difficulty  separated  his  teeth  more  than  one-fourth  of  an  inch."  Sub- 
sequently, ligation  of  the  right  primitive  carotid  was  performed 
for  supposed  hemorrhage  from  the  posterior  auricular.  "  The  liga- 
ture was  placed  a  short  distance  below  the  bifurcation,  and  coagula 
were  removed,  and  the  ball,  already  mentioned,  was  extracted  from 
near  the  angle  of  the  jaw."  The  patient,  however,  died  from  subse- 
quent hemorrhage,  on  the  eleventh  day  after  the  operation.  The 
condition  of  hearing  in  the  affected  ear  is  not  noted,  nor  is  the  char- 
acter of  the  injury  of  the  ear  mentioned. 

^  Italics  are  the  present  writer's. 


158  GUNSHOT    WOUNDS.  • 

The  following  case  is  related  under  wounds  and  injuries  of  the 
neck. 

Private  Frank  Eastman,  Co.  C,  Sixth  New  Hampshire  Volunteers, 
aged  18  years,  was  wounded  April  2d,  1865,  by  a  fragment  of  shell, 
which  entered  near  the  spinous  process  of  the  seventh  cervical  vertebra 
and  emerged  in  front  of  the  ear  on  the  right  side.  He  recovered  from 
the  injury  and  was  discharged  from  service  on  July  24th,  1865.  When 
Pension  Examiner  0.  H.  Boynten  reported  on  the  case,  November 
13th,  1865,  the  patient  suffered  from  deafness  in  the  right  ear,  and 
from  pain  and  dizziness.  It  is  stated  that  there  was  a  continuous  dis- 
charge of  matter  into  the  mouth  which  was  believed  to  come  from  the 
ear  through  the  right  Eustachian  tube.  The  patient  was  unable  to 
labor.  The  wood-cut  illustrating  this  case,  on  admission  to  Harwood 
Hospital,  Washington,  a  few  days  after  the  ^yound  was  received,  shows 
that  the  wounds  of  exit  and  entrance  were  greatly  lacerated,  and  were 
in  a  sloughing  condition. 

It  would  seem  that  in  this  latter  case,  caries  of  the  mastoid  cells  or 
of  the  osseous  walls  of  the  tympanum  must  have  existed,  and  that 
there  was  some  obstruction  of  the  external  auditory  canal  which  pre- 
vented an  escape  of  the  secretions. 

The  following  case  of  gunshot  wound  of  the  face,  implicating  the 
ear,  came  to  the  author  for  treatment,  November  26th,  1877,  on  ac- 
count of  an  acute  purulent  inflammation  of  the  middle-ear.  It  illus- 
trates well  the  disadvantage  of  partial  closure  of  the  external  auditory 
canal  in  preventing  the  free  escape  of  secretions  from  the  middle-ear. 

John  Farlow,  Company  D.,  11th  N.  Y.  Volunteers,  aged  20  years, 
was  wounded  in  the  face,  July  21st,  1861,  at  Bull  Kun,  by  a  ball  which 
entered  just  below  the  outer  angle  of  the  right  eye,  and  after  passing 
through  the  malar  bone,  at  its  articulation  with  the  superior  maxillary 
bone,  ranged  directly  backward  and  slightly  downward  through  the 
masseter  muscle  and  lodged  in  the  temporal  bone  above  the  glenoid 
fossa.  The  missile  was  probably  a  rifle  ball.  It  may  now  be  felt 
lying  beneath  the  integument  lining  the  external  auditory  canal. 
Soon  after  getting  up  he  found  that  the  hearing  of  the  right  ear  was 
greatly  impaired. 

When  the  author  examined  this  patient,  the  watch  only  could  be 
heard  -^j.  Vision  of  the  right  eye  was  almost  gone.  An  examination 
of  the  inner  end  of  the  canal  and  of  the  membrana  tympani  could 
not  be  made,  owing  to  the  presence  of  the  missile  which  is  very  prob- 
ably encysted. 

No  report  of  this  case  can  be  found  in  the  ''Medical  and  Surgical 
History  of  the  War  of  the  Kebellion."  It  is  believed  that  a  very  large 
nvimber  of  the  wounded  in  this  engagement  were  never  reported  to 
the  Surgeon-General's  office. 

The  editor  of  the  "Medical  and  Surgical  History"  selected  a  large 


GUNSHOT    WOUNDS.  159 

number  of  cases  of  wounds  of  the  eye  from  the  reports.  One  thou- 
sand one  hundred  and  ninety  cases  of  gunshot  wounds  of  this  organ 
are  thus  classified  as  occurring  in  "^  wounds  and  injuries  of  the  face." 
There  are  two  hundred  and  ninety-three  "  selected  cases  "  of  which 
abstracts  are  given.  In  two  hundred  and  fifty-four  cases  of  this  num- 
ber, one  eye  only  was  injured,  however,  and  among  these  were  thirty- 
nine  cases  of  fracture  of  the  temporal  bone,  or  other  injury  implicating 
the  ear.  One  can  readily  understand  how  a  bullet  coming  from  the 
front,  or  nearly  so,  could  wound  not  only  the  eye,  but  the  ear  also; 
and  it  is  difficult  to  avoid  the  conclusion,  from  the  perusal  of  these 
briefly  reported  cases,  that  had  more  detailed  examinations  and 
reports  been  made,  a  larger  number  of  aural  injuries  would  have  been 
selected. 

Wounds  and  injuries  of  the  jatvs  and  other  facial  hones,  as  was  to 
be  expected,  frequently  involved  the  ear.  Where  the  lower  jaw  is 
injured,  the  concussion  imparted  to  the  glenoid  fossa  may  give  rise  to 
inflammation  of  the  temporo-maxillary  articulation,  with  consequent 
inflammation  of  the  osseous  and  periosteal  structures  of  the  contigu- 
ous portion  of  the  external  auditory  canal.  Stenosis  of  the  canal  may 
thus  be  brought  about,  with  exclusion  of  sound;  or  an  extension  of 
the  inflammation  to  the  transmitting  mechanism  of  the  middle-ear 
may  occur,  giving  rise  to  altered  tension  in  the  drum-head,  or  other- 
wise injuring  this  part  of  the  ear. 

An  analysis  of  the  one  hundred  and  thirty-five  cases  of  gunshot 
fracture  of  the  facial  bones,  abstracts  of  which  were  made,  shows  that 
the  ear  was  injured  in  seventeen  cases — eight  by  wounds  of  entrance, 
and  nine  by  wounds  of  exit.  The  wounds  of  entrance  are  described 
as  follows:  In  one  case,  a  musket  ball  entered  "in  front  of  the  exter- 
nal auditory  canal  -of  the  left  side;"  in  a  second  case,  the  missile 
entered  "close  to  the  mastoid  process"  of  the  right  temporal  bone; 
in  another,  "behind  and  above  the  lobe  "  of  the  right  ear;  in  a  fourth, 
*'one  and  a  half  inches  below  the  ear;"  in  the  fifth  case,  "in  front  of 
the  left  ear;"  in  another,  "two  inches  behind  the  left  mastoid;"  in 
another,  "below  left  ear;"  in  an  eighth,  "just  anterior  to  the  tragus" 
of  the  left  ear. 

The  wounds  of  exit  were  stated  to  have  been  as  follows:  One  by 
"two  openings  in  front  and  below  the  pinna;"  one  "at  the  left  ear;" 
another  "behind  the  right  ear;"  another  "two  inches  behind  left 
ear;"  a  fifth  "emerged,  tearing  away  a  portion  of  the  lobe"  of  the  left 
ear;  one  "emerged  one  inch  below  lobe  of  right  ear;"  one  "lodged 
below  mastoid  in  exit"  at  right  ear;  another  "escaped  one  inch  below 


160  GUNSHOT   WOUNDS. 

the  ear'^  on  the  left  side;  and  one  "emerged  an  inch  behind  lobe  of 
left  ear." 

The  above  illustrates  very  well  the  various  channels  of  approach  to 
the  ear.  The  left  ear,  it  will  be  observed,  was  injured  in  nine  cases, 
and  the  right  ear  in  eight  cases.  In  the  eight  wounds  of  entrance,  the 
left  ear  was  injured  in  five  cases  and  the  right  ear  in  three  cases — 
showing  the  same  increased  frequency  of  left-sided  wounds  as  in  head 
wounds.  In  the  wounds  of  emergence,  the  right  ear  was  affected  in 
five  cases,  the  left  ear  in  four  cases. 

Facial  paralysis  occurred  as  a  result  of  these  injuries  in  three 
cases — in  two  instances  the  facial  nerve  was  apparently  injured  in  its 
passage  along  the  aquceductus  Fallopii,  and  in  the  other  after  its 
emergence  from  the  stylo-mastoid  foramen.  The  result  of  the  injuries 
was  fatal  in  five  cases.  In  six  of  these  cases  only  is  mention  made  of 
any  deafness  being  produced;  indeed,  in  the  whole  group  thus  classi- 
fied as  face  wounds,  the  ear  is  alluded  to  only  in  the  most  incidental 
manner.  In  one  case,  the  sense  of  taste  was  affected.  In  two  of  the 
cases,  discharge  from  the  ear  was  noted — the  same  being  purulent 
in  the  one  case  and  serous  in  the  other.  Vertigo  was  pronounced 
in  one  case. 

Circular  No.  3  of  the  Surgeon-General's  oflBce,  which  embraces 
the  reports  of  the  medical  officers  for  the  period  of  time  extending 
from  the  close  of  the  war  of  the  Rebellion,  in  1865,  down  to  1871, 
contains  some  contributions  of  interest  to  the  otologist.  The  follow- 
ing case  is  reported  by  A.  A.  Wood  hull.  Assistant  Surgeon  U.  S. 
Army: 

Soldier,  accidentally  wounded  near  Fort  Gibson,  Nov.  8th,  1868. 
The  ball  entered  the  side  of  the  neck,  traversed  the  mastoid  process, 
and  passed  through  the  external  ear;  *'  the  bone  was  slightly  injured, 
and  the  external  ear  nearly  destroved.^'  "  He  was  treated  in  hospital 
at  Fort  Gibson,  Cherokee  Nation,  until  Feb.  18th,  1868  (1869?), 
when  he  was  sent  to  join  his  company.^'  The  wound  was  nearly 
healed,  excepting  some  little  amount  of  discharge.  Partial  deafness 
also  existed. 

David  Walker,  Acting  Assistant  Surgeon,  reports  the  following 
case: 

A  cavalryman,  aged  22  years,  was  wounded  in  an  Indian  fight, 
September  6th,  1865.  *'  It  was  found  that  he  had  a  gunshot  wound, 
the  ball  having  entered  at  the  posterior  head  of  the  sterno-cleido-mas- 
toid  muscle,  close  to  the  curved  line,  ranging  outward  and  a  little 
upward,  and  lodging  in  the  mastoid  process.  There  was  consider- 
able hemorrhage  from  the  auditory  canal,  with  temporary  deafness. 


GUNSHOT    WOUNDS.  161 

and  paralysis  of  part  of  the  port io  dura  of  the  seventh  pair.     Ulti- 
mately the  recovery  was  complete." 

The  literature  of  military  surgery  of  the  present  century  does  not, 
naturally  enough,  contribute  much  to  the  science  of  otology.  A 
perusal  of  Guthrie's  ''Commentaries"''  fails  to  discover  but  a  single 
allusion  to  wounds  or  injuries  of  the  ear.  Hennen/  however,  devotes 
a  paragraph  to  the  subject,  and  narrates  one  case  of  wound  of  the  head 
where  a  musket  ball  entered  the  right  temporal  bone  and  lodged  in 
the  brain,  causing  ''partial  deafness  of  the  right  ear,"  among  other 
symptoms.  He  says:  "  Tlie  ear  is  the  subject  of  gunshot  wounds,  as 
various  as  the  eye,  in  their  course  and  in  their  effects.  The  mastoid 
process  is  injured  sometimes  in  its  whole  extent,  and  sometimes  only 
partially  brushed;  the  balls  passing  about  it  in  every  possible  angle^ 
and  sometimes  appearing  even  to  enter  the  external  meatus  itself^ 
at  all  events,  injuring  the  bony  circle  primarily,  and  in  its  conse- 
quences implicating  the  more  internal  bony  sides  of  the  auditory  canal, 
and  small  bones  of  the  organ,  in  suppuration  and  caries.  These  cases 
are  attended  with  more  or  less  deafness,  great  pain,  frequent  spas- 
modic affections  of  the  face,  and  an  intolerable  fetor  in  the  discharge; 
and  are  sometimes  followed  by  death  from  inflammation  spreading  to 
the  brain." 

Guthrie,  under  "  wounds  of  the  face,"  treats  somewhat  of  lesions  of 
the  ear.     These  will  be  alluded  to  hereafter. 

Macleod '  very  briefly  and  incidentally  mentions  four  cases  where 
the  ear  was  injured  by  musket  balls. 

In  one,  "a  French  soldier  received  a  ball  about  an  inch  behind  the 
left  ear;"  in  another  case  the  ball  "entered  two  inches  behind  the 
left  ear,  passed  deeply,  and  was  removed  from  the  temple,"  and  there 
was  hemorrhage  from  the  ear.  "  He  made  an  excellent  recovery,  only 
that  his  hearing  was  destroyed  on  the  wounded  side." 

Another  case  is  given  under  wounds  of  the  head,  in  the  appendix: 

"Compound  fracture  of  the  squamous  portion  of  the  left  temporal. 
Bleeding  from  the  ear.  Deafness  complete  on  left  side,  and  partial 
on  right.  Had  headache,  and  a  stupid,  vacant  expression  of  face 
when  sent  to  England." 

'  Guthrie.  G.  J.,  F.R.S.:  Commentaries  on  the  Surgery  of  the  War  in  Portu- 
gal, Spain,  France,  and  the  Netherlands,  from  the  battle  of  Roliga,  in  1808,  to 
that  of  Waterloo,  in  1815,  etc.     Revised  to  1853.     Fifth  edition.  London,  1853. 

'  Hennen,  John,  M.D.,  F.R.S.E.:  Principles  of  Military  Surgery,  etc;,  page 
279.     First  American  from  the  third  London  edition.     Philadelphia,  1830. 

■'  Macleod,  George  H.  B.,  M.D.,  F.R.C.S.:  Notes  on  the  Surgery  of  the  War 
in  the  Crimea,  etc.     1863. 
11 


162  GUNSHOT    WOUNDS. 

In  another  case  a  ball  was  "partially  impacted  a  little  above  and 
behind  the  right  ear,"  the  patient  subsequently  succumbing  to  hernia 
of  the  brain  after  trephining. 

Moos '  reported  three  cases  of  gunshot  wounds  of  the  ear,  all  of 
which  will  be  found  of  much  interest. 

A  soldier  was  wounded  at  the  battle  of  Worth,  August  6th,  1870, 
in  the  left  ear  and  in  the  right  knee.  The  ball  which  wounded  the 
■ear  "glanced  over  the  soft  parts  in  front  of  the  tragus  and  the  tragus 
itself,  and  had  produced  a  shallow,  granulating,  pretty  large  loss  of 
substance  before  the  left  ear;  it  had  torn  away  the  skinny  and  carti- 
laginous part  of  the  external  auditory  passage  in  such  a  way  that  the 
posterior  wall  of  the  osseous  canal  was  struck  where  the  same  is  joined 
to  the  mastoid  process."  There  was  partial  splintering  of  the  bony 
parts,  suppurative  inflammation  of  the  external  and  middle  ear,  and 
subsequently  peripheral  necrosis  of  the  mastoid  process  followed,  with 
Ijurrowing  abscess  extending  down  under  the  sterno-mastoid  muscle. 
The  track  of  the  ball  after  it  entered  the  cells  of  the  mastoid  process 
could  not  be  traced,  and  the  ball  was  not  found.  The  sense  of  hear- 
ing was  completely  lost.  Patient  underwent  amputation  of  the  thigh 
for  suppuration  of  the  knee-joint,  and  died  on  the  6th  of  September, 
1870.  Examination  of  the  temporal  bone  showed  that  the  posterior 
"wall  of  the  osseous  canal  had  been  splintered  by  the  passage  of  the 
ball,  and  that  the  opening  led  into  a  cavity  in  the  mastoid,  the  size 
of  a  hazelnut.  Downward  from  this  cavity  a  sinus  extended  into  the 
tissues  below.  The  tissues  of  the  middle  and  inner  ear  were  more  or 
less  inflamed. 

Inasmuch  as  no  facial  paralysis  occurred  in  this  case,  we  may  infer 
that  the  injury  was  confined  to  the  posterior  wall  of  the  canal  and 
outer  and  lower  portion  of  the  mastoid  body,  the  middle  ear  be- 
coming involved  through  extension  by  continuity.  It  seems  probable 
that  recovery  would  have  taken  place  here,  so  far  as  the  wound  of  the 
ear  was  concerned  at  least. 

The  second  case  was  examined  by  Moos  four  months  after  the 
injury  had  been  received: 

Soldier  wounded  at  the  siege  of  Strasbourg,  September  20th,  1870, 
by  a  Chassepot  ball  in  the  left  ear  from  behind  forward,  the  missile 
entering  on  the  lower  half  of  the  mastoid  process,  and  emerging  on 
the  left  side  of  the  face,  just  in  front  of  the  external  meatus  and 
cutting  away  the  tragus.  Paralysis  of  the  muscles  of  the  left  side  of 
the  face  resulted.  "The  perception  of  the  direction  of  sound  was 
completely  lost,  and  at  first  was  very  distressing  to  the  patient,  as  he 
constantly  thought  every  sound  came  from  the  right  side;  by  degrees 
he  learned  to  correct  this."  Tuning-fork  on  skull  was  perceived  only 
on  the  sound  side,  but  he  heard  the  watch  on  temple.  Moderately 
loud  words  spoken  through  a  trumpet  were  not  heard. 

*  Archives  of  Ophthalmology  and  Otology.     Volume  II.,  No,  1,  1871. 


GUNSHOT    WOUNDS.  163 

The  clinical  history  in  this  easels  incomplets:  On  being  struck, 
he  immediately  fell  to  the  ground,  became  unconscious,  but  gradu- 
ally and  completely  regained  his  faculties  during  the  next  twenty- 
four  hours.  The  first  six  days  he  suffered  from  violent  pains  in  the 
forehead  and  occiput.  He  had,  however,  "  no  subjective  sensations 
of  hearing,"  but  for  several  weeks  now  and  then  knockings  in  the 
depth  of  the  ear;  about  two  weeks  befoi-e  the  above  examination  was 
made,  however,  he  began  to  experience  tinnitus  aurium,  which  still 
existed. 

Prussian  soldier,  wounded  on  the  Lisaine,  January  18th,  1871,  by 
a  ball  which  "  struck  the  right  ear,  and  passed  below  the  left  side  of 
the  lower  jaw,  and  came  out."  The  only  injury  resulting  from  this 
appears  to  have  been  in  the  cartilaginous  meatus,  the  lower  wall  of 
which  was  slightly  lacerated. 

Mossakowski '  found  among  1,415  wounded  French  prisoners  but 
14  wounds  of  the  bony  parts  of  the  head.  Of  this  number  the 
forehead  was  the  seat  of  the  injury  in  1  case,  the  parietal  bones  in 
10,  and  the  temporal  bone  in  3  cases.  In  4  of  these  cases  severe 
cerebral  symptoms  developed,  and  in  4  of  them  hemorrhage  from  the 
ear  occurred.  Objective  examination  showed  that  of  these  14  inva- 
lids, 4  were  deaf  in  one  ear,  whilst  2  were  deaf  in  both  ears,  with 
severe  psychical  disturbance.  Special  aural  examinations  of  these 
patients  were  apparently  not  made. 

Gr.  Fischer  "  places  the  number  of  gunshot  wounds  occurring  in  the 
Franco-Prussian  War  at  88,877.  According  to  this  author,  the  head 
was  the  seat  of  injury  in  8,133  cases,  the  face  in  1,440  cases,  the  eyes 
in  464,  the  nose  in  210,  the  mouth  in  365,  the  chin  and  lips  in  348, 
and  the  ears  in  303  cases  (0.34^). 

In  examining  a  recent  work  on  ''  Military  Surgery  "  by  H.  Fischer,' 
the  writer  finds  some  very  instructive  cases  of  gunshot  injuries  of  the 
ear,  which  have  been  collected  from  the  reports  of  different  authori- 
ties. 

We  find  that  F.  Lofifller  observed  five  cases  of  gunshot  wounds  of 

1  Mossakowski,  Paul:  Statistischer  Bericht  liber  1415  franzosrsche  Invaliden 
des  Deutsch-franzosischen  Krieges,  1870-1871.  Deutsche  Zeitschrift  fiir 
Chirurgie,  Band  I.,  1872. 

-  Fischer,  Georg:  Statistik  der  in  dem  Kriege  1870-71,  im  preussischen 
Heere  und  in  den  mit  demselben  im  engeren  Verbande  gestandenen  Nord- 
deutschen  Bundes-Kontingenten  vorgekommenen  Verwundungen  und  Tod- 
tungen,     Berlin,  1876. 

^Fischer,  Prof.  Dr.  H.:    Handbuch  der  Kriegschirurgie,  Band  I.,  Stuttgart 
1883. 


164  GUNSHOT   WOUNDS. 

the  mastoid  process  and  bony  canal,  all  of  which  were  received  on  the 
18th  of  April,  1864,  at  the  storming  of  the  Danish  intrenchments  at 
Diippel  by  the  Prussians. 

Fischer  mentions  also  two  cases  reported  by  Beck,  in  one  of  which 
the  ball,  passing  through  the  mastoid  process,  penetrated  deeply  into 
the  petrous  portion  of  the  temporal  bone,  fracturing  the  base  of  the 
skull,  and  eventually  causing  death;  in  the  other  case  the  missile  en- 
tered the  external  auditory  canal  and  lodged  there,  extraction  being 
followed  by  recovery. 

Another  case,  observed  by  Stromeyer,  as  follows: 

Patient  received  a  bullet  at  a  short  distance  in  the  left  side  of  the 
head,  the  lobe  of  the  ear  being  slightly  injured  thereby.  On  the  mas- 
toid process  was  a  small  wound.  The  point  of  the  finger  being  intro- 
duced, found  the  whole  mastoid  to  have  been  completely  shattered. 
Eventually  the  whole  process  was  exfoliated,  and  the  patient  recov- 
ered with  not  the  slightest  impairment  of  hearing. 

We  find  also  an  interesting  case  of  Dudon  in  this  work: 

Patient,  17  years  of  age,  had  received  a  ball  from  a  carbine  in  the 
right  ear  four  and  one-half  years  before.  The  cerebral  symptoms 
which  followed  lasted  but  a  short  period,  and  nothing  remained  ex- 
cepting a  discharge  from  the  ear.  When  Dudon  examined  the  pa- 
tient, he  found  the  canal  filled  with  granulation  tissue.  The  bul- 
let was  easily  found  and  extracted.  The  drum-head  was  completely 
destroyed  and  hearing  entirely  gone.  Patient  recovered  with  loss  of 
hearing. 

The  following  is  a  very  remarkable  case,  reported  by  Luecke: 

Soldier,  wounded  in  the  Second  Schleswig-Holstein  war,  at  Alsen, 
June  29th,  1864,  by  a  small  canister  shot,  which  entered  in  front  of 
the  left  ear  at  the  height  of  the  helix,  tearing  a  large  hole  in  the 
squamous  portion  of  the  temporal  bone.  Out  of  this  wound,  and  also 
out  of  the  external  auditory  canal  oozed  a  very  considerable  amount 
of  blood  and  brain  substance.  The  missile  appears  to  have  passed 
downward,  completely  shattering  the  petrous  portion  of  the  tem- 
poral bone,  and  was  found  just  beneath  the  skin  near  the  spinous 
process  of  the  fourth  dorsal  vertebra.  Patient  was  able  at  first  to  tell 
his  name  and  the  number  of  his  regiment,  but  soon  lost  conscious- 
ness. "After  prolonged  suppuration  and  extraction  of  many  pieces 
of  bone,  he  was  discharged  as  an  invalid  in  January,  1865.  having  no 
other  lesion  excepting  paralysis  of  the  facial  and  acoustic  nerves." 
His  intellect,  however,  appears  to  have  suffered  severely,  and  his  life 
during  the  following  four  years  or  so  was  a  miserable  one.  He  was 
found  frozen  to  death  in  the  woods  finally. 

Two  cases  of  Loffler's,  given  by  Fischer  in  his  work  mentioned, 
above,  are  of  much  interest: 


GUNSHOT    WOUNDS.  165 

Soldier,  wounded  in  the  Schleswig-Holstein  War,  the  ball  entering 
the  right  external  meatus,  passing  through  the  posterior  wall  of  the 
latter  and  also  through  the  mastoid  process,  behind  which  it  was 
found  and  removed.  Complete  facial  paralysis  and  deafness,  also  loss 
of  bone  conduction  and  protrusion  of  the  right  orbit,  resulted.  Pa- 
tient recovered  eventually  with  loss  of  hearing  and  of  vision  on  the 
right  side  and  facial  paralysis. 

Soldier,  wounded  on  the  18tli  of  April,  1864,  at  Diippe],by  a  bullet 
v/hich  entered  just  in  front  of  the  right  ear,  shattered  the  mastoid 
and  was,  at  the  autopsy,  found  lodged  between  the  latter  and  the 
jaw.  The  last  mentioned  bone  and  the  styloid  process  were  also 
shattered.  Patient  died  on  the  loth  day  after  the  injury,  from  puru- 
lent meningitis.     The  petrosa  was  found  to  be  fractured. 

Fischer  finally  gives  the  following  case,  as  illustrating  the  danger 
by  which  such  patients  are  constantly  surrounded,  as  long  as  a  dis- 
charge from  the  ear  exists  : 

A  sergeant,  v/ouuded  on  April  18th,  1864,  in  Schleswig-Holstein, 
by  a  bullet  which  penetrated  just  in  front  of  the  left  ear,  shattered 
the  zygomatic  arch  and  passed  through  the  external  auditory  canal, 
fracturing  the  drum-head,  and  perforated  also  the  mastoid  process, 
becoming  finally  lodged  in  the  neck  near  the  fourth  cervical  vertebra. 
Facial  paralysis  and  complete  loss  of  hearing  resulted,  with  which 
the  patient  was  eventually  discharged,  a  slight  otorrhoea  being  also 
present.  About  a  year  after  this  he  had  an  attack  of  convulsions, 
having  experienced  for  some  days  previously  pains  in  the  head  and 
ear.  He  died  the  following  day  from  purulent  meningitis,  with  ab- 
scess of  the  brain.  Partial  necrosis  of  the  petrous  portion  of  the  tem- 
poral bone  existed  and  also  an  ununited  fracture  of  the  same  bone. 

Gillette,  in  speaking  of  the  wounds  made  by  firearms,  mentions 
the  fact  that  bullets  occasionally  lodge  in  the  petrosa,  and  cites  a  case 
reported  by  Lecoin,  who  found  the  ball  lodged  in  the  interior  of  that 
l)one.  Gillette'  also  mentions  a  case  observed  by  Guyon,  of  a  young 
woman  with  facial  paralysis  consecutive  to  a  revolver  shot  fired  into 
the  ear,  the  missile  being  then  firmly  lodged  in  the  petrosa.  Other- 
wise the  patient  was  perfectly  well. 

The  above  citations  embr^jce  about  all  that  the  author  has  been  able 
to  obtain  from  the  works  on  military  surgery  at  hand,  concerning 
gunshot  injuries  of  the  ear,  v/ith  some  few  exceptions  to  which  allu- 
sion will  be  made  later  on. 

Now  and  then  opportunities  have  been  afforded  for  observation  of 
self-inflicted  gunshot  wounds  of  the  ear,  this  organ  seeming  to  be  one 

'  Gillette  :  Remarques  sur  les  blessures  par  armes  a  feu  observees  pendant 
le  Siege  de  Metz  (1870)  et  celui  de  Paris  (1871).  Archives  generales  de  M6de- 
cine.    Vol.  I,.  Paris,  1873. 


166  GUNSHOT    W0DND8. 

of  the  favorite  channels  for  discharging  a  missile  into  the  head  by 
the  suicide.  Out  of  eleven  cases  of  suicide  by  gunshot  wounds  of  the 
head,  reported  in  Circular  No.  3  of  the  Surgeoii- General's  Office, 
1871,  four  of  them  were  from  shots  in  and  about  the  ear.  All  gun- 
shot wounds  of  the  ear  are  liable  to  have  other  injuries  associated 
with  them  and  may  therefore  come  under  the  care  of  the  general  sur- 
geon, and  detailed  reports  of  them  are  not  often  given.  The  above 
examples  of  fuHy  described  cases  are  therefore  introduced  on  account 
of  their  particular  instructiveness. 

Prof.  Geo.  E.  Post,'  M.D.,  of  Beirut,  Syria,  reports  a  case  of  much 
interest. 

The  patient,  a  man  22  years  of  age,  was  asleep  when  a  revolver  was 
accidentally  discharged  directly  into  his  right  ear  by  his  little  brother. 
He  experienced  the  sensation  of  being  awakened  by  a  clap  of  thunder. 
Copious  hemorrhage  from  the  ear,  severe  headache,  impairment  of 
hearing  and  distressing  tinnitus' aurium  followed.  There  was  con- 
siderable febrile  action,  and  for  weeks  the  symptoms  were  grave. 
When  he  finally  recovered  sufficiently  to  leave  the  house,  he  was  still 
quite  unable  to  resume  his  occupation  (tailor).  Efforts  made  in 
Damascus  by  the  military  surgeons  to  remove  the  ball  from  the  mea- 
tus by  means  of  forceps  and  the  screw  tire-balle,  were  unsuccessful, 
and  although  particles  of  lead  were  removed,  the  bullet  was  not  dis- 
turbed in  the  slightest  degree.  The  patient  was,  when  seen  by  Post, 
suffering  from  hemicrania,  dizziness,  tinnitus,  otorrhcea,  and  an  ina- 
bility to  concentrate  his  attention  on  any  subject.  The  bullet  was  felt 
at  the  end  of  the  meatus,  but  could  not  be  moved.  Believing  the  ball  to 
have  been  impacted  in  the  mastoid  cells,  it  was  decided  to  remove  it 
by  an  operation.  The  pavilion  was  dissected  free  along  its  mastoid 
border,  and  separated  from  its  deep  attachments,  the  dissection  being 
also  carried  behind  the  meatus  externus  until  this  was  quite  free  from 
the  mastoid  process.  **  It  was  then  divided  from  behind  forwatd,. 
along  the  line  of  junction  with  the  bony  meatus,  and  the  pavilion, 
with  the  cartilaginous  portion  of  the  meatus,  were  turned  forward  on 
the  cheek.''  "  The  posterior  bony  wall  of  the  meatus  was  found 
shattered  by  the  bullet,  which  was  then  plainly  seen,  filling  the  cavity 
of  the  tympanum,  and  extending  by  many  ragged  projections  back 
into  the  mastoid  cells."  Attempts  to  dislodge  it  with  the  forceps  and 
the  tire-balle  were  fruitless.  The  bullet  was  finally  removed  after  the 
mastoid  process  had  been  trephined.  Patient  made  a  good  recovery 
in  three  weeks,  being  relieved  of  all  his  grave  and  distressing  symp- 
toms. 

A  case  of  compound  fracture  of  the  petrous  bone,  caused  by  a  re- 
volver bullet,  is  reported  by  Mr.  E.  M.  James. ^ 

A  man,  aged  25  years,  shot  himself  in  the  right  ear  with  a  revolver. 

'  New  York  Medical  Record.     October  26th,  1878. 
^Australian  Medical  Journal.     September  15th,  1880. 


GUNSHOT   WOUNDS.  167 

There  v/as  severe  primary  hemorrhage.  Mr.  James  found  a  lacerated 
wound  at  the  bottom  of  the  concha  of  the  right  ear.  The  adjacent 
parts  were  blackened,  blood  oozed  freely  from  the  wound,  and  there 
was  facial  paralysis  of  the  right  side.  There  was  marked  hyper- 
aesthesia  about  the  shoulders,  especially  on  the  right  side.  Motions 
of  the  limbs  unimpaired.  A  probe  introduced  into  the  wound  passed 
inwards  and  slightly  backwards  to  a  depth  of  half  an  inch.  It  was 
found  that  the  track  of  the  ball  lay  inwards  and  slightly  forwards. 
The  ball,  not  being  felt,  was  supposed  to  have  passed  into  the 
cranium.  I'he  mastoid  was  then  trephined  from  behind  forwards  on 
to  the  point  of  a  probe  inserted  through  the  original  wound.  The 
bullet  could  not,  liowever,  be  recognized  by  the  probe  introduced 
along  the  opening  made  by  the  trephine,  and  further  search  was 
abandoned.  Patient  was  conscious  some  of  the  time  at  first  and 
suffered  much,  but  afterwards  became  delirious  and  sensitive  to  light 
and  noises.  On  the  sixth  day,  the  discharge  from  the  ear  was  very 
great;  death  on  the  seventh  day.  At  the  autopsy,  it  was  found  that 
"a  bullet,  weighing  nearly  a  quarter  of  an  ounce,  had  passed  through 
the  concha  of  the  right  ear,  involving  the  external  meatus;  it  then 
penetrated  the  skull,  and  running  inwards  had  struck  against  the  base 
of  the  petrous  bone,  which  was  fractured  transversely  near  its  outer 
extremity,  and  more  or  less  separat  d  from  all  its  usual  connections; 
the  anterior  part  of  the  bone  was  also  splintered  off  longitudinally.'' 
"The  ball  itself  was  firmly  fixed  in  the  floor  of  the  tympanum,  the 
walls  of  which  were  largely  destroyed,  while  its  roof  was  broken  into 
small  fragments,  so  that,  when  the  dura  mater  was  removed,  there 
was  a  gap  in  the  floor  of  the  middle  fossa  of  the  skull  nearly  half  an 
inch  in  diameter.  On  the  outer  suriace  of  the  detached  petrous  bone, 
the  projecting  promontory  of  the  inner  ear  was  discernible.  The 
dura  mater  was  not  perforated,  but  was  detached  from  the  injured 
bone,  being  separated  from  it  by  a  mixture  of  lymph  and  extravasated 
blood.  There  was  no  blood  in  the  arachnoid  cavity."  "The  tissues 
at  the  site  of  the  main  lesion  had  evidently  been  contused  and  subse- 
quently inflamed.  The  inflammation  had  spread  inwards  and  forwards 
along  the  base  of  the  brain,  the  pia  mater  being  thickened  by  exuda- 
tion of  lymph  into  its  substance;  there  was  a  considerable  quantity  of 
serous  fluid  in  the  arachnoid  at  the  base  of  the  brain.*'  The  bullet 
was  found  imbedded  in  the  floor  of  the  tympanum,  and  "was  with 
difficulty  recognized,  and  some  degree  of  force  was  necessary  to  dis- 
lodge it."  "The  cause  of  death  was  meningo-cerebritis  consequent 
upon  a  compound  fracture  of  the  skull,  attended  with  bruising  of  the 
brain." 

Dr.  J.  0.  Green  published  the  following  case:' 

A  man,  aged  40  years,  with  suicidal  intent  fired  two  shots  from  a 
small  revolver  directly  into  the  right  external  auditory  meatus,  the 
immediate  effect  being  "absolutely  negative."  The  patient,  when 
seen  four  days  afterwards,  had  some  dull  pain  over  the  right  side  of 
the  head,  and  some  tenderness  of  the  right  ear  and  same  side  of  face. 

'  Transactions  of  the  American  Otological  Society.     1881.     P.  471. 


168  GUNSHOT   WOUNDS. 

There  was  facial  paralysis,  but  no  visible  lesion  about  the  external 
ear.  Pulse  and  temperature  normal;  no  dizziness.  "Examination 
with  the  speculum  and  reflected  light  showed  the  deeper  meatus  filled 
with  black  masses  of  half-burnt  powder,  and  with  a  probe  loose  foreign 
bodies  could  be  felt  deep  in."  There  was  a  moderate  discharge  of 
discolored  serum  from  the  ear.  The  entrance  of  the  meatus  was 
unusually  small.  On  the  sixth  day,  "a  semi-circular  incision  was 
made  above  and  behind  the  auricle,  through  the  periosteum,  and  the 
periosteum  with  the  auricle  and  cartilaginous  meatus  carried  forward 
till  the  edge  of  the  osseous  meatus  was  reached;  the  insertion  of  the 
cartilaginous  to  the  osseous  passage  was  then  cut  through  in  its  upper 
and  posterior  part."  After  turning  the  auricle  forward,  an  irregular 
bit  of  lead  was  extracted  by  the  forceps,  after  which  the  anterior  wall 
of  the  meatus  was  removed.  Another  mass  of  lead  was  found  im- 
pacted deep  in,  and  with  considerable  difficulty  removed.  Still  another 
large  mass  of  lead  was  removed,  found  firmly  fastened  in  the  deepest 
part  of  the  meatus.  The  auricle  was  then  replaced,  sutures  applied 
and  antiseptic  dressings.  The  patient  did  well  until  five  days  after 
the  operation,  when  he  became  sullen  and  refused  food.  On  the  sixth 
day  he  was  attacked  with  vertiginous  symptoms  and  became  delirious. 
Death  occurred  on  the  seventh  day.  The  autopsy  showed,  among 
other  conditions,  a  slight  greenish  discoloration  over  the  petrous 
bone,  due  to  serum  beneath  the  pia.  *' Just  above  the  roof  of  the 
tympanum,  the  dura,  pia,  and  brain  substances  were  firmly  adherent  " 
to  the  bone.  Above  this,  a  sinus  entered  the  brain,  passing  upwards 
for  half  an  inch,  "evidently  the  track  of  a  piece  of  one  bullet." 
"Small  fragments  of  bone  imbedded  in  the  dura  at  this  point." 
" Pachymeningitis  existed  over  the  right  convexity."  The  temporal 
bone,  when  examined,  showed  that  *'the  whole  anterior  wall  of  the 
osseous  meatus  down  to  the  tympanic  ring  was  wanting;  the  tissues 
in  front  of  the  ear  and  around  the  glenoid  fossa  were  gangrenous. 
The  roof  of  the  tympanum  was  perforated  by  an  opening  eight  milli- 
metres long  and  four  millimetres  broad;  this  opening  being  covered 
by  the  inflamed  and  adherent  dura,  and  corresponding  with  the  bullet 
track  of  the  brain.  The  bone  within  the  tympanum  was  entirely 
denuded;  no  trace  of  any  of  the  ossicles  could  be  found,  and  the  lower 
edge  of  the  fenestra  ovalis  was  broken  away,  making  a  large  opening 
into  the  vestibule,  and  the  promontory  around  this  opening  was  black. 
No  trace  of  any  lead  was  found  within  the  bone." 

Terrillon'  reported  a  very  interesting  case  where  extraction  of  the 
ball  was  followed  by  recovery: 

Patient,  a  man  28  years  of  age,  had  received  a  shot  from  a  revolver 
some  four  months  before.  The  missile  appears  to  have  entered  the 
external  auditory  canal  in  a  slightly  oblique  and  upward  direction. 
Great  hemorrhage  and  pain  followed,  and  severe  inflammatory  symp- 
toms. These  seemed  to  have  passed  away  in  the  course  of  a  month. 
however,  leaving  the  patient  perfectly  healthy,  excepting  a  purulent 

'  Annates  des  Mai.  de  Toreille  et  du  larynx.     Paris.  1878.     IV. 


GUNSHOT   WODNDS.  169 

-discharge  from  the  fistulous  openii)g  in  the  canal  where  the  bullet 
had  entered.  There  was  also  complete  deafness  in  this  ear.  Symp- 
toms of  cerebral  trouble  did  not  exist.  On  probing,  this  ball  was 
found  lying  about  two  and  a  half  centimetres  from  the  entrance  of 
the  fistulous  opening  posteriorly  and  above,  and  firmly  Sxed  in  the 
bone.  All  attempts  to  remove  it  through  the  opening  failed,  and  it 
was  finally  extracted  only  after  the  pavilion  of  the  ear  had  been  dis- 
sected free  from  its  attachments  to  the  mastoid  bone.  The  recovery 
of  the  patient  was  a  rapid  one. 

The  following  case  occurred  in  the  author's  own  practice: 

Patient,  a  male  19  years  of  age,  was  shot  with  a  revolver  (22  car- 
tridge) in  the  left  ear,  March  12th,  1884,  by  a  person  standing  to  the 
left  side  and  somewhat  behind  him.  He  fell  to  the  ground  at  once 
from  the  shock,  was  slightly  confused  for  a  few  minutes,  but  got  up 
and  walked  without  aid,  although  he  felt  slightly  dizzy.  There  was 
some  hemorrhage  at  first  from  the  ear,  but  this  soon  ceased.  When 
admitted  to  the  hospital,  he  was  dizzy,  had  a  slight  headache,  and 
some  tinnitus.  He  could  only  hear  a  watch  on  contact  in  the  wounded 
ear.  The  tragus  was  slightly  abrased,  and  in  it  was  imbedded  a  small 
piece  of  lead.  The  drum-head  was  fractured,  and  the  lower  wall 
of  the  canal  was  considerably  lacerated.  Efforts  to  find  the  ball 
during  the  next  few  days  failed.  Some  pain  in  the  ear  and  a  puru- 
lent discharge  developed.  Tinnitus  was  also  present  at  times.  When 
seen  by  the  writer,  eighteen  days  after  the  injury,  a  purplish  cyst  was 
found  on  the  superior  wall  of  the  meatus,  due  to  burrowing  of  secre- 
tions from  the  attic  (?),  which  partially  occluded  the  lumen  of  the 
canal.  The  latter  was  filled  with  pus.  A  perforation  was  seen  in  the 
posterior  segment  of  the  drum-head.  The  lower  bony  wall  of  the 
canal,  from  the  tympanum  outwards,  was  much  denuded,  the  lacerated 
tissues  bleeding  easily.  A  Nelaton  probe  rubbed  forcibly  over  the 
entire  exposed  lower  wall  of  the  canal,  and  also  as  far  as  possible  in 
the  tympanum,  came  away  without  any  marks  of  lead.  A  probe  could 
be  passed  down  between  the  cartilaginous  and  bony  walls,  and  some- 
what anteriorly,  but  without  encountering  the  bullet.  Movement  of 
the  jaw  was  free.  There  were  no  vertiginous  symptoms  but  tin- 
nitus, like  escaping  steam.  Low  voice  could  be  heard  in  the  injured 
ear  at  ten  feet  distance.  During  the  patient^s  stay  in  the  hospital,  all 
attempts  to  find  the  ball  proved  fruitless.  He  left  the  hospital  in 
three  weeks'  time,  and  was  then  suffering  much  from  dizziness. 
During  the  following  eight  or  nine  weeks  there  was  a  more  or  less 
purulent  discharge  from  the  ear,  with  occasional  attacks  of  pains  and 
dizziness.  The  canal  was  much  occluded  with  granulation-tissue,  but, 
by  means  of  local  applications,  had  been  much  enlarged. 

At  this  time  a  vulcanite  dilator  was  introduced,  by  means  of  which 
the  meatus  was  much  enlarged  in  three  days'  time,  and  was  free  even 
in  the  osseous  portion  for  a  short  distance.  The  discharge  was  also 
considerably  less.  The  canal  finally  was  free  enough  to  permit  a 
view  of  the  drum-head.  In  the  anterior  superior  quadrant  of  the 
membrana  flaccida  there  was  a  perforation  through  which,  on  Val- 


170  "  GUNSHOT    WOUNDS. 

salva,  dark  colored  pus  exuded.     A  perforation  in  the  posterior  seg- 
ment of  the  membrana  vibrans  remained. 

Nearly  six  months  after  the  injury  had  taken  place,  a  dark 
object  was  seen  lying  against  the  inner  wall  of  the  tympanum. 
It  could  be  easily  moved  with  the  probe,  but  it  was  impossible  to  ex- 
tract it  with  the  curette.  After  this  the  patient  failed  to  appear  for 
some  six  months.  His  condition  was  then  about  the  same.  Several 
months  later  he  was  finally  persuaded  to  undergo  an  attempt  at  ex- 
traction, under  narcosis.  Some  small  fragments  of  lead  were  brought 
away  with  the  forceps,  which  were,  however,  too  slight  to  retain  their 
hold.  The  bullet  was  seen  through  the  speculum,  being  quite  mov- 
able in  the  tympanic  cavity.  The  patient  was  told  to  return  on  a 
subsequent  day,  at  which  time  suitable  forceps  had  been  provided, 
but  he  failed  to  do  so 

A  review  of  the  cases  of  gunshot  injury  occurring  in  warfare,  and 
of  which  a  number  of  histories  have  been  given  above,  will  bring  to 
light  some  very  interesting  facts. 

Mention  has  been  made  above  of  sixteen  cases  of  aural  injury 
from  gunshot  wounds,  which  were  found  in  the  "  Medical  and  Sur- 
gical History."  An  analysis  of  this  group  shows  that  in  two  of  them 
only  was  a  discharge  from  the  external  auditory  canal  noted,  and  in 
two  of  them  facial  paralysis  occurred.  Of  these  sixteen  cases  ten 
were  on  the  left  side,  three  on  the  right,  and  in  three  the  ear  affected 
is  not  stated.  The  greater  frequency  of  occurrence  on  the  left  side 
was  doubtlessly  owing  to  the  fact  that  the  wounded,  with  two  excep- 
tions (a  medical  officer  serving  with  a  battery,  and  an  artilleryman), 
belonged  to  the  infantry  and,  when  wounded,  were  engaged  in  the 
act  of  discharging  their  own  muskets,  and  must  have  been,  therefore, 
presenting  the  left  side  of  the  head  to  the  enemy. 

In  twenty-nine  cases,  where  the  ear  was  the  seat  of  direct  injury, 
hy  entrance,  it  is  found  that  the  left  side  was  struck  fourteen  times, 
the  right  in  nine  cases,  whilst  in  six  the  ear  injured  is  not  mentioned; 
thus  showing  the  greater  frequency  here  of  left  sided  gunshot  "wounds 
to  the  ear. 

In  all  of  these  cases  the  missiles  were  musket  balls,  with  but  one 
exception,  where  the  injury  was  caused  by  a  canister  shot  (see  case 
of  Luecke,  p.  164).  We  find  furthermore  that  in  these  twenty-nine 
cases,  the  mastoid  was  the  point  of  entrance  of  the  missile  in  twelve, 
the  external  auditory  canal  in  five,  and  the  squamous  portion  of  the 
temporal  bone  in  four  cases.  The  ball  entered  immediately  in  front 
of  the  external  auditory  canal  in  five  eases  and  in  the  immediate 
vicinity  of  the  lobe  of  the  ear  in  three  cases. 

Besides  the  two  cases  of  facial  paralysis  occurring  among  the  six- 
teen cases  of  aural  injury  mentioned  in  the  "  Medical  and  Surgical 


GUNSHOT   WOUNDS.  l71 

History,"  and  to  which  allusion  has  Just  been  made,  we  find  that 
this  Ifesion  was  one  of  the  results  of  the  gunshot  Avouhds  in  seven 
other  cases,  including  those  of  Gruyou,  James  and  Green. 

In  observing  the  effects  of  gunshot  wounds  of  the  organ  of  hear- 
ing it  will  be  seen  that  the  middle  ear  may  be  affected  in  different 
ways.  A  simple  rupture  of  the  membrana  tympani  may  take  place, 
or  disturbances  of  its  tension,  with  consequent  deafness  and  tinnitus. 
The  ball  may  become  impacted  in  the  tympanic  cavity,  after  having 
wounded  the  external  parts  of  the  ear  in  its  passage ;  if  entering 
from  behind  the  mastoid  would  be  perforated — laterally  the  external 
auditory  canal  and  probably  the  mastoid  cells.  Missiles  (musket 
balls)  coming  directly  into  the  middle  ear  the  length  of  the  canal,^ 
would  very  probably  produce  a  fatal  result. 

The  mastoid  process,  it  will  have  been  remarked,  is  very  liable  to 
gunshot  injur}',  the  missile  entering  from  behind  and  from  the  front. 
When  the  result  is  not  fatal,  obliteration  of  the  cells  with  permanent/ 
external  opening  and  communications  with  the  middle  ear  (usually 
the  transmitting  mechanism  is  destroyed)  will  follow. 

The  external  auditory  canal  may  be  injured  by  missiles  coming 
from  almost  all  directions.  Wounding  of  the  cartilaginous  portion 
may  lead  to  stricture  or  there  may  be  occlusion  of  the  osseous  portion 
of  the  canal,  owing  to  deposition  of  new  bony  tissue.'  The  missile 
may  lodge  in  the  walls  and  impinge  on  the  calibre  of  the  canal.  The 
result  may  thus  be  the  exclusion  of  sound,  the  alteration  of  the  ten- 
sion of  the  transmitting  mechanism,  tinnitus  and  deafness.  There  is, 
of  course,  a  danger  of  subsequent  middle-ear  inflammation  in  these 
cases. 

The  auricle  may  be  carried  away  by  a  musket  ball  or  by  larger  mis- 
siles. In  the  ''Medical  and  Surgical  History"  seven  instances  are 
found  where  the  auricle  was  cut  off  by  ''larger  projectiles,  either 
cannon-shot,  shell  fragments,  or  grape."  In  two  cases  great  mutila- 
ation  of  the  auricle  was  produced  by  musket  balls.  "  Of  these  nine 
patients,  six  were  returned  to  duty,  with  the  sense  of  hearing  believed 
to  be  as  acute  as  ever,  and  as  the  three  who  were  discharged  cannot 
be  traced  on  the  pension  rolls,  it  is  probable  that  their  disabilities 
were  not  serious."  The  loss  of  the  auricle  may,  however,  entail  de- 
fective orientation  and  imperfect  collection  of  sound,  and  probable  in- 
jury to  the  tension  of  the  conductive  mechanism,  with  consequently 
more  or  less  deafness  and  tinnitus  aurium.  Union  may  take  place 
with  occlusion,  if  care  be  not  taken  in  replacing  the  detached  auricle. 


172  SABRE    WOUNDS. 


SABRE  WOUNDS. 


The  abstracts  of  incised  wounds  of  the  scalp  oz*  cranium  in  the  First 
Section  of  the  Medical  and  Surgical  History  of  the  War  of  the  Rebel- 
lion give  the  history  of  thi-ee  hundred  and  thirty-one  cases  of  this  in- 
jury. These,  it  is  stated,  ''comprise  all  of  the  sabre  or  sword  cuts 
of  the  head  entered,  on  the  registers  of  the  Surgeon-General's  Office, 
that  can  be  satisfactorily  verified.  Others  are  alluded  to  by  medical 
officers,  but  so  indefinitely,  that  identification  has  been  impracticable.' 
Although  the  temporal  region  is  stated  to  have  been  frequently 
wounded  in  these  cases,  the  author  can  find  no  reference  to  any  in- 
juries of  the  ear. 

The  face  was  injured  in  thirty-seven  instances  by  sabre  cuts  and  in 
twenty-seven  by  bayonet  thrusts.  The  compiler,  in  regard  to  wounds 
of  this  region,  states  that  "the  abstracts  of  face  injuries  selected 
comprise  few  of  the  ear.  The  wounds  of  the  auricle  were  either  in- 
frequent or  else  regarded  as  of  insufficient  importance  to  be  particu- 
larized." This  the  writer  can  well  understand,  since  he  himself  saw  a 
considerable  number  of  sabre  wounds  of  the  scalj)  and  auricle,  which 
were  received  in  the  engagement  at  Front  Royal,  Va.,  May  23d,  1862, 
where  cavalry  were  actively  engaged  on  both  sides.  Some  of  the 
cases  came  under  his  own  observation  a  week  later  when  General 
McDowelFs  advance  reached  Front  Royal.  Nearly  all  the  wounds 
seen  then  had  been  dressed  by  bringing  the  parts  together  with  adhe- 
sive plaster,  and  sometimes  with  stitches,  and  were  doing  so  well  that 
no  further  attention  was  necessary  at  that  time.  Abstracts  of  none 
of  these  cases  appear  in  the  published  reports,  and  it  seems  probable 
that  a  very  large  number  of  such  patients  were  never  reported  to  the 
Surgeon-General's  Office. 

Sabre  wounds  of  the  ear  were  much  more  frequent  in  the  warfare 
of  ancient  times  than  they  have  been  of  late.  Ambrose  Pare  states 
that  the  ears  are  sometimes  wholly  cut  off;  sometimes  only  in  part, 
and  again  in  other  cases  only  slit  so  that  the  rent  portion  still  ad- 
heres. Since  the  more  general  employment  of  firearms  in  -warfare 
has  been  in  vogue,  however,  the  frequency  of  sabre  wounds  has 
greatly  decreased,  although  some  allusion  to  such  injuries  may  be 
found  in  the  writings  of  Guthrie,  Hennen,  Larrey  and  other  military 
surgeons  who  enjoyed  remarkable  opportunities  for  observation  during 
the  great  European  wars  in  the  early  part  of  the  present  century. 
Hennen  regards  sabre  wounds  of  the  ear  as  very  simple. 

Treatment. — It  seems  to  be  the  opinion  of  all  writers  on  this  sub- 
ject that  when  the  ear  has  been  cut  off  entirely  all  efforts  to  restore 


SABRE    WOUNDS. 


17S 


it  again  will  be  unsuccessful.  Pare  says  that  so  long  as  the  rent 
portion  adheres  to  the  rest  it  may  be  made  to  re-unite  by  means  of 
sutures.  He  strongly  advises  against  passing  the  needle  through  the 
cartilage,  however,  since  gangrene  might  occur  from  such  a  proceed- 
ing. After  securing  the  edges  of  the  wound,  including  only  the  skin 
and  tissues  covering  the  cartilage,  the  rest  of  the  cure  comprises  the. 
employment  of  pledgets  and  ligatures  carefully  adjusted.  Special 
care,  however,  should  be  taken,  says  Pare,  that  the  severed  parts  be 
so  adapted   that   in   uniting  no   obstruction   of  the  auditory  canal 


Fig.  28. 


result,  interfering  with  the  entrance  of  sound,     A  piece  of  punk  is 
recommended  for  this  purpose,  to  be  introduced  into  the  meatus. 

Larrey'  does  not  agree  with  Pare  respecting  the  use  of  sutures,  for 
he  lays  down  the  rule  that  the  cartilages  of  the  ear  should  be  included 
within  the  stitches  of  the  suture,  since  "  no  unpleasant  symptom  will 
result  from  it,  and  the  suture  will  only  be  the  more  exact  and  firm." 
Care  should  be  taken,  says  Larrey,  "to  fill  up  with  charpie  the  in- 

'  Larrey,  Baron  D.J.,  Observations  on  Wounds  and  their  Complicationa,. 
etc.     Translated  by  E.  F.  Rivinus,  M.D.     Phila.  1832. 


174  SABRE    WOUNDS. 

termediate  spaces  of  the  sinuosities  of  the  ear  and  the  channel  by  which 
it  is  separated  from  the  temple."  The  dressing  is  then  to  be  com- 
pleted by  a  retaining  bandage,  which  should  not  be  disturbed  until 
complete  cicatrization  has  taken  place. 

In  operations  on  the  organ,  it  may  furthermore  be  stated,  the 
auricular  cartilage  serves  the  purpose  of  a  splint,  and  when  any 
bandaging  becomes  necessary,  the  surgeon  may  avail  himself  of  the 
unyielding  surface,  over  which  the  pinna  is  spread,  to  keep  the  parts 
in  place. 

When  the  divisions  are  unequal  or  jagged,  owing  to  the  inequal- 


FiG.  29. 

ities  of  the  instrument  with  which  the  injury  has  been  inflicted,  it 
is  necessary  to  cut  the  edges  of  the  division  smooth  before  bring- 
ing the  parts  together,  otherwise  there  is  apt  to  be  a  want  of  uni- 
formity in  the  cicatrix. 

In  regard  to  the  treatment  of  lacerated  and  incised  wounds  of  the 
ear  in  general,  it  may  be  said  that  surgeons  do  not  now  hesitate  as 
formerly  to  employ  sutures  in  bringing  the  edges  of  the  cartilage  to- 
gether, and  deformities  of  the  organ  from  injuries,  therefore,  do  not 
often  occur.  Even  when  the  auricle  has  been  almost  entirely  de- 
tached frotn  the  head,  it  may  be  successfully  restored.  The  accom- 
panying cut  (Fig.  28),  taken  from  photograph,  shows  the  auricle  of 


ARROW     WOUNDS.  175 

a  man,  in  whom  in  childhood  tlie  organ  was  nearly  sevei-ed  from  its 
attachments  by  the  injury  inflicted  by  a  cart  wheel.  The  wound 
was  dressed  by  a  person  who  happened  to  be  present,  and  did  well. 
The  position  of  the  auricle  was  excellent  so  far  as  appearance  was 
concerned  (unless  viewed  from  behind,  as  seen  in  Fig.  29),  but  it  so 
happened  that  the  meatus  was  closed  by  the  cartilage  of  the  concha. 
It  is  important,  therefore,  that  the  surgeon,  in  order  to  obviate  such 
a  result,  should  insert  a  plug  into  the  external  auditory  meatus  in 
these  cases,  thus  keeping  the  canal  open  until  the  parts  have  healed 
entirely. 

The  writer  saw  another  case,  similar  to  the  one  just  described, 
where  almost  complete  detachment  of  the  auricle  occurred  from  the 
kick  of  a  horse. ' 

ARROW   WOUNDS. 

Injuries  of  the  ear  from  arrow  wounds  are  now  so  rare  as  to  scarcely 
entitle  them  to  mentio7i  here,  although  in  ancient  warfare  tliey  were 
probably  very  frequent.  Of  the  fifteen  cases  of  arrow  wound's  of  the 
head,  face,  and  neck,  reported  in  Circular  No.  3,  the  author  finds 
two  instances  where  the  ear  was  injured  ;  in  one  of  these  cases  there 
was  ''a  slight  cat  from  an  arrow  in  the  left  ear,*'  and  in  the  other 
an  iron  arrow-head  lodged  in  the  petrous  portion  of  the  right  tem- 
poral bone.  It  has  been  observed  that  where  wounding  by  arrows 
has  occurred,  the  patient  has  generally  received  multiple  wounds 
fi'om  this  cause  ;  fatal  wounds  were  thus  received  in  both  of  the 
•cases  mentioned. 

'  Amer.  Journal  of  Otology,  Vol.  4,  p.  48. 


CHAPTER  X. 

WOUNDS    AND     INJURIES    OF    THE    DRUM-HEAD    AND 
DRUM   OF   THE   EAR. 

These  may  be  limited  to  the  drr.m-head,  but  it  should  be  borne  in 
mind  that  they  usually  include  the  drum  also,  either  as  a  result  of 
simultaneous  wounding  or  subsequent  extension  of  inflammation. 
Traumatic  lesions  of  the  drum-head  are  caused  :  ( 1 )  by  blows  upon 
the  ear  with  the  open  hand  or  fist  ;  (2)  by  blows  with  missiles  ;  (3) 
by  falls  upon  the  ear  ;  (4)  by  the  violent  impact  of  intense  sounds  or 
concussive  force,  as  (a)  the  concussion  from  the  blast  of  projectiles  or 
great  guns,  (b)  from  the  blast  of  small  arms  or  small  explosives,  (c) 
from  long-continued  musketry  fire,  rapid  firing  machine  guns,  etc., 
(d)  the  impact  of  steam  whistles,  loud  voice  or  of  other  intense  sounds, 
as  metal  hammering  ;  (5)  by  concussion  or  penetration  of  objects 
thrust  into  the  jear  ;  (6)  by  violent  entrance  of  water  in  syringing  the 
ear  and  in  surf  bathing  ;  (7)  by  violent  traction  on  the  auricle  ;  (8) 
by  sudden  condensation  of  air  in  the  drum ;  (9)  by  the  impact  of 
ceruminal  plugs ;  (10)  by  the  rarefaction  of  air  external  to  the  drum- 
head, as  in  diving  and  in  the  compressed  air  of  caissons  ;  (11)  by  the 
introduction  of  molten  metals,  scalding  fluids,  steam  or  strong  acids  ; 
(12)  by  shot  wounds;  (13)  by  lesion  of  the  drum  in  fracture  of  the 
temporal  bone. 

I.  TRAUMATIC  LESIONS   OF   THE   DRUM-HEAD   CAUSED 

BY  BLOWS   UPON   THE   EAR  WITH   THE   OPEN 

HAND   OR  FIST. 

Nearly  all  blows  upon  the  side  of  the  head  may  injure  the  ear,  and 
thus  range  themselves  under  this  category.  The  custom  of  ear-box- 
ing is  of  long  standing  ;  thus,  according  to  ancient  writers,  the  clas- 
sical boxer  regarded  the  ear  as  the  most  vulnerable  part  for  the  inflic- 
tion of  a  blow  with  the  deadly  cestus.  But,  later  on,  early 
Christianity  aimed  a  blow  against  this  pagan  custom,  and  with 
unflinching  fortitude  the  non-combatant,  when   smitten   upon  one 


WOUNDS    AiSTD    INJURIES    OF    THE    DRUM-HEAD.  177 

cheek,  meekly  presented  the  other  to  the  still  persistent  advocate  of 
corporal  punishment.  And  it  is  due  to  this  kindly  example  that 
custom  uo  longer  sanctions  the  practice,  though  the  principle  upon 
which  it  was  founded  may  have  been  almost  forgotten. 

But  a  great  amount  of  heedless  and  brutal  punishment  is  still  in- 
flicted in  this  way,  not  only  by  pugilists  and  contestants  generally, 
but  also  by  teachers,  parents,  and  others  who  find  that  a  punch  about 
the  ears  is  generally  a  painful  and  most  effectual  means  of  chastise- 
ment. 

Though  corporal  punishment,  in  general,  is  less  in  vogue  than 
formerly,  the  writer  has  found  51  cases  among  his  records,  embracing 
almost  every  variety  both  as  regards  causation  and  results,  where  the 
ear  has  been  injured  by  blows  of  the  open  hand  or  fist.  Viewed  from 
a  clinical  standpoint,  it  was  found  that  31  of  these  were  males,  and. 
20  were  females  ;  of  the  males,  13  were  boxed  upon  the  right  ear, 
13  upon  the  left,  and  3  of  them  upon  both  ears.  One  was  kicked  by 
a  companion  upon  the  left  ear  while  bathing,  and  the  right  ear  of  1 
was  injured  by  having  the  head  violently  squeezed  between  the  hands 
of  another  person.  Of  the  females,  14  were  struck  upon  the  left  ear, 
and  6  upon  the  right.  Five  of  the  women  were  assaulted  by  pugilistic 
spouses,  which  may  account  for  the  disproportionate  injury  to  the 
left  ear,  since  this  side  is  most  obnoxious  to  a  right-handed  blow. 

Though  evasive  and  incorrect  answers  were  often  given,  inquiries 
elicited  the  fact,  that  of  the  entire  number  8  were  boxed  in  play,  4 
by  rigorous  pedagogues,  2  by  parental  disciplinarians  (the  number  of 
these,  of  course,  was  actually  much  greater),  and  1,  a  fervent  lover, 
received  a  chilling,  backhanded  slap  upon  the  ear  from  his  indignant 
sweetheart,  effectually  cooling  his  ardor  as  well  as  upsetting  his 
equilibrium.  The  facts  in  this  last  case,  like  many  others,  only  came 
out  long  after  a  misleading  statement  had  been  first  made. 

Several  cases  occurred  among  pugilists,  the  left  ear  being  usually 
struck  in  cross-counter.  Others  were  due  to  assaults,  brawls,  and 
contests  generally. 

The  writer,  in  reflecting  on  this  subject,  has  been  puzzled  not  a 
little  at  the  comparatively  small  number  of  persons  coming  to  our 
public  clinics  with  aural  trouble  produced  in  the  manner  under  con- 
sideration. But  when  it  is  considered  that  but  few  have  any  idea  of 
the  meaning  of  the  disagreeable  symptoms  caused  by  concussion  of 
the  ear  and  its  consequences,  one  need  no  longer  wonder  that  the  in- 
jured organ  receives  no  attention.  Indeed,  it  can  be  readily  under- 
stood that  persons  rude  and  thoughtless  enough  to  box  the  ears  of 
children  will  neglect  them  afterward.  Thus  but  six  children  came 
12 


178  WOUNDS    AND    INJURIES    OF   THE   DRUM-HEAD. 

expressly  for  treatment  for  recent  ear-boxing,  though  a  large  number 
coming  for  other  affections  of  the  ear  could  recall  having  had  it  slapped 
or  pulled  previously,  and  having  had  subsequently  severe  pain,  dis- 
tressing noises,  and  vertigo— symptoms  enough,  truly,  to  subdue  un- 
ruly children,  or  even  a  prize-fighter,  for  that  matter. 

One  cannot  lay  too  much  stress  on  the  social  aspect  of  this  subject, 
since  the  medical  adviser  may  be  entirely  misled  in  respect  to  the 
causation.  Deafness  itself  is  not  usually  a  noticeable  feature  in  chil- 
dren, especially  so  long  as  one  ear  is  fairly  useful ;  nor  is  the  yet  more 
distressing  symptom  of  autophonia  in  its  various  forms.  It  is  only 
when  pain  is  unendurable,  a  discharge  offensive  to  others,  or  instruc- 
tion difficult,  that  the  conscience-stricken  or  reticent  parent  ac- 
knowledges the  facts  on  which  a  correct  diagnosis  may  be  made.  A 
striking  case  in  point  occurs  to  the  writer.  It  was  that  of  a  youth, 
eighteen  years  of  age,  who  was  brought  to  the  New  York  Eye  and 
Ear  Infirmary  by  his  mother,  on  account  of  an  acute  purulent  in- 
flammation of  the  middle-ear  with  suspicious  symptoms  of  intracranial 
trouble.  He  gave  the  history  of  a  discharge  from  the  affected  (right) 
ear  ever  since  it  had  been  boxed  when  he  was  six  years  of  age.  The 
present  exacerbation  was  due  to  the  rapid  growth  and  consequent 
pressure  of  a  large  polypus.  He  was  advised  to  have  the  tumor  re- 
moved and  place  himself  under  treatment,  but  being  very  nervous 
«,nd  timid,  he  lacked  courage  to  consent  to  the  operation.  Getting 
temporarily  better,  he  failed  to  return.  About  a  year  after  this, 
much  more  serious  vertigo,  with  other  brain  symptoms,  occurred 
suddenly,  and  after  a  brief  illness  he  died  in  great  agony.  The 
autopsy  revealed  caries  of  the  petrous  bone  and  pachymeningitis. 
The  father  of  the  boy  communicated  the  final  result  to  the  writer, 
and  with  much  feeling  stated  that  it  was  he  himself  who  had  struck 
the  blow  upon  the  ear  which  had  thus  finally  resulted  in  his  son^s 
death. 

Another  case  was  that  of  a  young  man,  aged  twenty-two,  whose 
father  had  given  him  a  blow  upon  the  left  ear  six  years  previously. 
Severe  inflammation  of  the  middle-ear  followed,  lasting  for  tw^o  years, 
during  which  time  the  air  whistled  through  a  perforation  in  the 
drum-head  whenever  he  blew  his  nose.  When  seen,  the  drum-head 
was  found  thickened,  irregular,  and  otherwise  changed  almost  be- 
yond recognition.  Hearing  was  very  much  impaired,  and  for  this 
relief  was  sought. 

In  yet  another  instance  of  this  kind  the  patient,  a  young  man 
aged  twenty,  was  slapped  upon  the  left  ear  by  his  father.  There  was 
immediate  pain  and  deafness,  followed  in  a  few  hours  by  a  watery 


WOUNDS    AND    INJURIES    OF   THE   DRUM-HEAD.  179 

discharge,  which  afterward  was  tinged  with  blood.  When  seen  at 
the  Infirmary,  two  days  after  the  boxing,  a  perforation  in  the  lower 
segment  of  the  drum-head  was  giving  vent  to  a  free  discharge,  and 
the  middle-ear  inflammation  was  complicated  with  periostitis  externa- 
the  mastoid  cortex  being  swollen,  red,  and  tender  to  the  touch, 
Autophonia,  noises  in  the  head,  and  pain  occurred  at  the  begin, 
ning,  and  were  very  distressing  for  a  long  time,  recovery  not  taking 
place  for  three  months. 

The  grave  consequences  of  pounding  the  ear  were  well  shown  in  a 
case  of  a  woman,  addicted  to  drink,  aged  thirty-eight,  who  was  struck 
violently  by  a  man  upon  the  right  ear  in  an  altercation.  The  immediate 
result  was  severe  dizziness,  and  she  had  to  hold  on  to  a  stair-railing 
to  keep  from  falling.  Vertiginous  symptoms  became  more  severe, 
and  the  pain  and  autophonia  with  this  alarmed  her  very  much.  She 
was  taken  to  a  dispensary,  where  an  energetic  attendant,  feeling  that 
something  must  be  done,  vigorously  inflated  the  ear  by  Politzer's 
method,  causing  extreme  pain  in  the  ear,  and  afterward  introduced 
some  irritating  medicament  on  cotton  wool  with  instructions  to  keep 
it  in  the  ear.  After  this  the  pain  became  more  severe  and  she  came 
to  the  Eye  and  Ear  Infirmary,  where  the  drum-head  was  examined. 
This  was  found  to  be  ruptured.  An  enormous  quantity  of  serous  fluid 
was  escaping  from  the  ear,  which  was  believed  tx)  consist  largely  of 
the  water  of  the  labyrinth,  thus  indicating  that  the  round  window  had 
also  been  ruptured  by  the  blow.  She  had  now  become  extremely  ner- 
vous ajid  experienced  insane  hallucinations,  as  was  confirmed  by  the 
physician,  who  saw  the  case.  She  was  admitted  to  the  wards  of  the 
Infirmary,  and  purulent  inflammation  of  the  middle-ear  soon  set  in. 
The  cerebral  symptoms — jDain,  vertigo,  hallucinations,  etc. — became 
more  grave.  They  seemed  due  in  part  to  the  concussion  of  the  blow; 
but  on  reviewing  the  ease  the  author  is  convinced  that  there  was  also 
transmission  of  a  septic  irritant  through  the  cerebro-spinal  fluid  into 
the  cranial  cavity,  inducing  leptomeningitis.  The  patient  left  the 
Infirmary,  where  her  presence  proved  a  great  inconvenience  to  others, 
before  she  was  well,  and  when  last  heard  from,  a  month  after  the  in- 
jury, had  not  recovered. 

One  not  uncommon  result  of  a  blow  or  fall  on  the  ear,  might  as" 
well  be  mentioned  here.  A  ceruminal  plug  is  sometimes  impacted 
with  considerable  force  against  the  drum-head  in  this  manner.  The 
contusion  causes  pain  ;  if  the  plug  lies  long  in  contact  with  the  drum- 
head inflammation  may  ensue. 

Rupture  of  the  driim-hend  occurs  not  so  much  in  consequence  of 
t\iQ  force  with  which  blows  are  delivered  upon  the  side  of  the  head  as 


180  WOUNDS  AND  injurif:s  of  the  drum-head. 

from  the  violence  of  aerial  compression  in  the  external  auditory  canal. 
Blows  thus  causing  sudden  concussion  may  come  from  above  or  below 
the  ear,  or  from  the  front  or  rear.  Occasionally  they  fall  perpendicu- 
larly to  the  external  auditory  meatus.  In  the  majority  of  instances, 
however,  compression  takes  place  through  the  rapid  collapse  of  the 
outstanding  cartilaginous  framework  down  upon  the  orifice  of  the 
canal.  Where  the  canal  is  large,  condensation  is  much  more  effective 
than  where  it  is  very  narrow.  Pugilists  and  contestants  experience 
repeated  ruptures  of  the  drum-head,  and  examination  of  the  parts 
will  often  show  very  marked  deformities.  In  two  cases  observed,  the 
patients  exhibited  rupture  of  the  drum-head  in  either  ear  from  blows 
simultaneously  inflicted. 

Traumatic  injury  of  the  mastoid  is  said  to  sometimes  rupture  the 
drum-head,  but  in  cases  of  this  kind  seen  by  the  writer,  while  having 
mastoid  contusions,  they  wei*e,  on  careful  inspection,  found  to  also 
exhibit  evidence  of  blows  upon  the  auricle  at  the  same  time.  A  very 
gentle  slap,  it  must  be  remembered,  may,  under  favorable  circum- 
stances, rupture  the  drum-head,  especially  in  elderly  people,  in  whom 
it  is  more  friable.  Obscure  head  symptoms,  which  are  often  experi- 
enced after  falls  or  blows  upon  the  side  of  the  head,  so  slight  that  in- 
jury of  the  hearing  organ  has  not  been  suspected,  should  therefore 
suggest  an  examination  of  this  organ.  Boxing  the  ear,  moreover,  is 
known  to  strain  or  contuse  the  drum-head  without  actual  rupture. 

Subjective  St/mptoms. — Violent  concussion  of  the  drum  of  the  ear 
gives  rise  to  more  or  less  disturbance  of  its  tension.  Numbness  about 
the  ear  and  certain  acoustic  phenomena,  as  autophonia  and  tinnitus, 
are  experienced.  The  patient  at  first  is  usually  also  confused  oi" 
stunned.  The  degree  of  consequent  vertiginous  phenomena  corresponds 
to  the  concussive  force  and  the  damage  done,  but  of  the  fifty-one  cases 
herein  cited,  only  one  was  actually  felled  by  the  blow,  and  none  were 
made  unconscious. 

Nervous  shock  or  cerebral  concussion  is  not  so  great  as  would  be  ex- 
pected when  it  is  considered  with  what  force  the  indriven  drum-head 
acts  upon  the  ossicles.  The  stapes,  however,  owing  to  the  peculiar 
construction  of  the  transmitting  mechanism,  cannot  be  driven  with 
undue  force  into  the  oval  window  in  which  its  base  is  fixed,  though 
the  concussive  force  from  without  entirely  destroys  the  drum-head. 
In  extremely  violent  concussions,  however,  the  drum-head  does  not 
always  offer  sufficient  resistance  to  the  force  of  impact  to  protect  the 
round  window  from  rupture  ;  its  excursions  under  such  conditions 
may  at  least  give  rise  to  labyrinthine  concussion.  Such  cases  are, 
however,  extremely  rare  as  a  result  of  a  blow  of  the  hand  or  fist.     Or- 


WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD.  181 

dinarily  the  disturbance  of  equilibrium  is  slight  and  of  brief  dura- 
tion. Occasionally  it  lasts  for  days  or  weeks,  and  more  or  less  dizzi- 
ness may  be  experienced  for  an  indefinite  period. 

Pain  is  usually  an  immediate  symptom,  though  not  invariably  so ; 
it  may  commence  only  as  reactive  inflammation  comes  on,  that  is  to 
say,  in  few  hours,  or  as  a  result  of  meddlesome  treatment.  In  inten- 
sity it  varies  from  slight  discomfort  to  great  suffering.  Its  duration 
depends  on  the  extent  of  contusion,  subsequent  inflammation,  and 
the  nervous  temperament  of  the  patient. 

Deafness  in  cases  of  slight  injury  may  be  scarcely  perceptible.  It 
is  rarely  very  great  at  the  beginning,  and,  other  symptoms  causing 
more  distress,  it  is  liable  to  be  overlooked.  It  is,  for  the  most  part, 
due  to  consecutive  inflammation  of  the  drum,  and  therefore  need  not 
be  considered  here.  A  mere  slit  in  the  membrana  vibrans  scarcely 
impedes  its  oscillations  in  a  perceptible  degree ;  nor  does  contusion 
of  the  membrana  flaccida.  Slight  inflammation  of  the  mucous  lining 
of  the  drum,  however,  causes  greater  or  less  deafness. 

Various  phenomena,  both  objective  and  subjective,  attend  trauma 
of  the  drum  of  the  ear.  The  sudden  and  violent  tension  of  the  trans- 
mitting mechanism  gives  rise  to  a  sound  like  the  twang  of  a  musical 
chord,  or  the  sound  of  a  vibrating  bell  or  tuning-fork.  Rupture  of 
the  drum-liead  announces  itself  to  the  patient  with  an  explosive  sound 
like  the  rupture  of  a  small  bladder  or  the  discharge  of  a  gun.  Some- 
times the  ringing  and  explosive  sounds  are  both  of  them  heard. 
Subjective  noises  supervene,  common  to  middle-ear  affections. 

AutopJionia  is  a  very  constant  symptom.  The  resonance  of  the 
drum,  upon  which  it  partly  depends,  varies  with  the  degree  of  swell- 
ing and  the  amount  of  fluid  present.  When  the  ear-drum  or  other 
localities  in  the  head  reached  by  the  air-passages  thus  becomes  reso- 
nant to  the  voice  or  other  sounds,  the  confusion,  and  even  alarm,  of 
some  patients  is  very  great. 

Xumhness. — The  sensitive  nerves  of  the  temporal  region  are  often 
found  in  a  hyperjesthetic  state,  the  parts  giving  rise  to  "tingling" 
sensations  when  touched. 

Perforation  whistle  may  afford  the  only  intimation  of  rupture  of 
the  drum-head,  where  a  slight  blow  upon  the  ear  has  been  given. 
The  escape  of  air  on  inflation  of  the  drum,  however,  is  not  always  of 
a  whistling  character,  since  the  quality  of  the  sound  depends  on  the 
size  and  shape  of  the  vent  in  the  drum-head  and  the  patulcncy  of  the 
Eustachian  tube.  Any  considerable  inflammation  of  the  drum,  where- 
by its  lining  membrane  becomes  thickened,  thus  diminishing  its 
cavity  and  obstructing  the  air  from  the  Eustachian  tube,  or  an  accu- 


182  WOUNDS   AND   INJURIES    OF    THE    DRUM-HEAD. 

mulation  of  secretions,  would  affect  the  character  of  this  sound.  The 
difficult  escape  of  air,  or  its  passage  along  with  fluids,  gives  rise  to 
peculiar  noises,  very  different  from  the  whistling  to  be  heard  several 
yards  away  when  the  drum  cavity  is  dry  and  the  opening  happens  to 
be  of  the  proper  size. 

Objective  Symploma. — The  drum-head  is  at  first  congested,  the  in- 
jection being  greatest  in  the  membrana  flaccida,  and  usually  extending 
down  along  the  malleus  handle  where  the  network  composing  the 
malleus  plexus  of  vessels  becomes  prominent.  But  this  clears  up  again 
in  a  few  hours,  unless  inflammation  ensues,  and  slight  vascularity 
only  remains  in  the  edges  of  any  wounds  produced  by  the  injury. 

Multiple  ruptures  occur,  but  generally  they  are  single  and  situated 
in  the  lower  segment — most  frequently  in  the  posterior  portion  of 
this.  They  vary  in  size  and  shape  ;  often  they  are  triangular,  a  flap 
being  left  attached  at  one  of  the  sides  of  the  defect.  Some  are 
straight,  some  semilunar  or  variously  curved. 

Course. — Large  and  irregular  rents  are  not  always  attended  by 
displacement,  but  when  the  edges  do  not  approximate,  any  loose 
flap  generally  sloughs  away  and  leaves  an  irregular  perforation.  The 
edges  of  perforations,  though  irregular  at  first,  afterward  become 
more  and  more  smooth  as  suppuration  continues,  and  the  opening 
may  remain  permanently.  Where  there  is  displacement  only,  or 
where  the  parts  are  not  kept  at  rest,  healing  is  delayed  ;  but  in  the 
more  favorable  cases  it  takes  place  rapidly  by  primary  union.  Med- 
dlesome treatment,  of  course,  protracts  the  case,  and  if  middle-ear  in- 
flammation occurs  from  this  or  other  cause,  affairs  become  compli- 
cated. In  the  greater  number  of  instances  spontaneous  and  complete 
union  may  be  expected.  Suppuration  protracts  some  cases  very 
much,  the  reproductive  process  being  slow,  and  opacities,  comprising 
areas  of  cicatricial  tissue  of  various  sizes,  remain.  If  a  large  area  of 
the  drum-head  lias  been  lost,  a  manometric  cicatrix  often  develops  it- 
self. 

In  the  51  cases  under  discussion  the  progress  was  as  follows:  7  were 
unattended  with  any  discharge  throughout;  6  had  a  serous  discharge 
only,  and  in  none  of  the  above  were  any  inflammatory  symptoms 
observed.  In  6  cases  there  was  decided  inflammation  of  the  drum 
and  swelling  of  the  drum-head,  but  no  discharge.  In  25  cases  sup- 
purative inflammation  of  the  drum  occurred  with  greater  or  less 
severity.     In  7  cases  the  particulars  in  this  regard  were  not  noted. 

Prognosis. — This  is  favorable  in  most  instances;  even  where  there 
has  been  suppuration,  the  drum-head  finally  heals.  The  hearing-power 
is  nearly  always  restored  where  a  mere  rupture  occurs.     AVhere  there 


WOUNDS   AND    INJURIES   OF   THE   DRUM-HEAD.  183 

has  been  suppuration  of  the  drum  or  other  complications,  hearing 
will  be  more  or  less  impaired.  Some  of  the  writer's  cases  were  cured 
in  a  few  days  without  remaining  injury,  while  others  did  not  recover 
for  as  many  months.  Several  protracted  cases  were  seen  where,  from 
neglect  or  maltreatment,  the  ear  had  been  discharging  for  a  period  of 
ten  years  or  more.  In  one  case,  this  condition  had  existed  for  thirty- 
seven  years.  In  these  protracted  cases  a  great  loss  of  hearing-power 
existed. 

Diagnosis. — If  the  ear  is  examined  early  enough,  or  before  inflam- 
mation has  set  in,  the  diagnosis  will  not  be  difficult.  It  is  well  to 
bear  in  mind  that  the  slight  traction  made  upon  the  cartilage  of  the 
external  ear,  necessary  on  introducing  the  speculum,  may  produce 
congestion  of  the  drum-head,  which  is  thus  made  more  tense.  This 
congestion  is  indistinguishable  from  that  caused  by  boxing  or  pull- 
ing the  organ.  A  perfectly  normal  drum-head  may  thus  be  made  to 
appear  to  have  been  injured. 

Blood  or  serum,  sometimes  both,  not  infrequently  trickle  from  the 
ear  immediately  after  the  drum-head  is  ruptured,  and  when  the  parts 
are  examined  soon  afterward,  traces  of  this  may  be  seen.  Later  on, 
inspissated  clots  only  are  usually  visible.  Sometimes  they  are  limited 
to  the  line  of  fissure  and  aid  in  retaining  its  edges  in  contact.  Where 
the  contusion  has  been  great,  an  area  of  membrane  assumes  the  ap- 
pearance of  a  blood-clot,  and  may  slough  or  remain  while  reproduction 
goes  on  underneath.  In  some  cases  the  drum-head  swells  rapidly,  all 
traces  of  blood-stained  fissures  and  other  landmarks  being  obliterated. 
In  other  cases  healing  is  so  rapid  that  nearly  all  traces  disappear  in  a 
few  days,  so  that  even  an  expert  can  discover  them  with  difficulty* 
AVhen  injuries  are  not  seen  until  swelling  has  masked  the  outlines, 
they  will  often  be  found  quite  distinguishable  again  after  its  subsi- 
dence. 

Ruptures  from  boxing  occur  for  the  most  part  in  the  membrana 
vibrans,  while  contusions  and  lacerations  from  pulling  the  auricle  oc- 
cur in  the  membrana  flaccida.  If  not  observed  for  ten  days  or  a  fort- 
night after  the  injury,  the  slit-like  or  ragged-edged  wound  usually 
assumes  a  regular  ovoidal  shape  in  cases  where  suppuration  takes 
place. 

A  differential  diagnosis  becomes  more  difficult  when  inflammation 
of  the  drum,  from  causes  other  than  traumatic,  exists  before  the  in- 
jury, or  arises  subsequently. 

The  escape  of  air  on  inflation  of  the  drum  is  an  infallible  sign  of 
perforation  of  the  drum-head ;  it  may  be  detected  with  the  diagnostic 
tube  when  the  perforation  whistle  is  not  well  marked. 


184  WOUNDS    AND    INJURIES    OF   THE   DRUM-HEAD. 

The  author  has  never  seen  adhesion  of  the  drum-head  to  the  inner 
wall  of  the  tympanum  take  place  as  the  result  of  injur}'  from  boxing 
the  ear,  though  this  may  occur  as  a  consequence  of  severe  inflamma- 
tory action. 

The  appearance  of  the  drum-head  a  few  days  after  traumatic  rup- 
ture is  sometimes  suggestive  of  fracture  of  the  malleus  handle, 
and  the  first  examination  is  thus  -often  deceptive.  In  a  case 
of  rupture  bisecting  the  drum-head  transversely,  examined  for  the 
first  time  nine  days  after  the  injury,  the  malleus  handle  seemed  to  be 
fractured  at  about  its  middle  ;  but  as  the  swelling  subsided  it  began 
to  appear  that  no  such  injury  existed. 

In  comparatively  slight  swelling,  the  landmarks  become  indistinct, 
or  even  obliterated  altogether  ;  but  as  healing  takes  place  these  are 
again  restored.  Suspicions  in  respect  to  this  injury  were  not  in  any 
instance  verified. 

Treatment. — It  is  a  safe  rule  to  abstain  from  doing  anything.  In 
most  of  the  protracted  cases  seen  by  the  writer,  there  was  given  a  his- 
tory of  meddlesome  treatment  from  the  beginning.  When  intra-tym- 
panal  air  renewal  is  active,  as  shown  by  oscillatory  movements  of 
the  drum-head  during  respiration,  the  patient  should  be  cautioned 
against  inflating  the  drum  voluntarily.  When  its  presence  is  borne, 
a  quantity  of  boracic  acid  with  calendula  may  be  introduced  by  means 
of  insufflation.  This,  when  no  discharge,  or  scarcely  any,  exists, 
quickly  forms  itself  upon  the  membrane,  preventing  undue  mo- 
tion. The  presence  of  inspissated  sero-sanguinolent  effusion  upon  the 
outer  surface  of  the  drum-head  affords  protection  and  should  not  be 
removed  by  syringing.  In  the  more  protracted  cases  where  the  pow- 
der is  not  borne,  the  instillation  of  succus  calendula?  proves  gently 
stimulating  to  the  granulating  edges  of  the  wound,  and,  on  drying, 
forms  a  thin,  protecting  film  of  calendulin  over  the  wound.  The 
most  simple  case  may  be  aggavated  by  active  management,  such  as  in- 
flation, syringing,  the  instillation  of  irritants,  and  the  like.  Inflam- 
mation of  the  middle-ear  thus  set  up  cannot,  however,  be  considered 
in  this  connection. 

THE   MEDICO-LEGAL   ASPECT   OF    BOXING    THE   EAR. 

Claudius,  in  pouring  a  "leperous  distilment"  (juice  of  hebenon) 
from  a  vial  ''into  the  porches  of  his  brother's  ear,"  with  murderous 
intent,  could  not  have  done  the  harm  that  often  follows  a  thought- 
less box  upon  the  ear.  Thus  it  has  been  shown  that  the  functions 
of  this  delicate  organ  may  be  greatly  impaired  by  a  comparatively 
slight  assault. 

Kedress  for  assaults  of  this  kind  is  sometimes  sought  in  the  coifrts 


WOUNDS    AND   INJURIES    OF    THE    DRUM-HEAD.  185 

of  law.  In  two  cases  of  recent  date  coming  to  the  writer's  knowledge, 
the  plaintiff  was  successful  in  both  instances.  In  one  of  them.  Pro- 
fessor Boyesen,  of  Columbia  College,  was  sued  in  the  City  Court  for 
15,000  damages. 

The  suit  was  brought  by  a  boy  through  his  father,  Alfred  E.  J. 
Tovey,  editor  of  the  Breivers  Journal,  his  guardian  ad  litem,  before 
Judge  Hawes  and  a  jury.  It  was  stated  that  defendant  struck  the 
boy,  who  was  then  seven  years  of  age,  on  the  head.  From  the  testi- 
mony, as  reported  in  the  Times  newspaper  of  May  6th,  1885,  it  would 
seem  that  the  boy  received  a  slap  with  the  hand  which  did  not  knock 
him  down.  The  father  testified  that  his  son  was  not  deaf  prior  to  the 
assault,  and  that  he  had  since  been  under  medical  care.  It  was  sug- 
gested by  the  defence,  which  contended  that  only  a  gentle  slap  had 
been  given,  that  the  trouble  might  have  arisen  from  colds,  or  from 
having  bathed  in  the  sea.  A  witness  testified  that  the  boy  went  into 
the  water  too  often,  and  that  he  was  slightly  deaf  before  the  assault. 

The  jury  decided  that  the  defendant  must  pay  $400  damages. 

In  another  case,  Marwig  vs.  Davies,  large  damages  were  claimed; 
the  case  was  settled  by  the  defendant  consenting  to  the  entry  of  a 
judgment.  Mr.  Newcombe,  the  plaintiff's  counsel  in  this  case,  states 
that  the  "  defendant  struck  the  child — he  fell  on  a  rock — producing 
temporary  deafness.     Our  action  was  for  the  assault." 

As  medical  jurists,  we  must  bear  in  mind  that  the  extent  of  aural 
injury,  where  the  patient  has  been  assaulted  by  a  blow  upon  the  side 
of  the  head,  is  not  to  be  measured  by  the  force  of  impact,  but  rather 
by  the  nature  of  the  blow.  Thus,  in  one  instance  the  force  of  a 
violent  assault  may  expend  itself  without  injury  of  the  hearing  organ, 
while  in  another  a  very  slight  tap  upon  the  temporal  region,  by  sud- 
denly compressing  the  air  in  the  external  auditory  canal,  may  con- 
tuse and  rupture  the  drum-head.  It  has  been  said  already  that  a 
simple  rupture  should  be  let  alone,  since  in  healthy  persons  it  soon 
heals.  It  is  the  purulent  inflammation  that  ensues  in  catarrhal  sub- 
jects, or  from  maltreatment,  that  causes  most  of  the  trouble  m  these 
cases.  In  persons  with  general  catarrh  of  the  upper  air  tract,  trau- 
matic injuries  of  the  ear  seem  disposed  to  suppurate.  Head  catarrh, 
coming  on  subsequently  to  trauma,  like  injudicious  treatment,  will 
generally  protract  these  cases  very  much. 

Where  a  wound  of  the  drum-head  has  in  this  manner  become 
chronic,  so  to  speak,  a  diagnosis  is  difficult.  Hence,  in  order  to  deter- 
mine the  exact  degree  of  injury  from  traumatism,  an  expert  examina- 
tion must  be  made  early.  Thus,  where  an  examination  has  been 
postponed,  the  rupture  no  longer  presents  a  slit-like  appearance,  but 


186  WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 

has  assumed  a  more  or  less  ovoidal  shape,  as  has  been  above  stated, 
and  cannot  now  be  distinguished  from  perforations  due  to  chronic 
purulent  inflammation  from  causes  other  than  traumatic. 

It  appears  to  the  writer  that  the  assailant  is  not  the  only  person  to 
be  held  accountable  for  the  results  of  injudicious  treatment  or  neg- 
lect; for,  although  the  legal  rule,  in  New  York  at  least,  as  to  lia- 
bility in  actions  for  damages  for  injuries  to  the  person  arising  from 
tortious  acts  seems  to  be,  that  although  the  original  tort-feasor  is 
ordinarily  liable  only  for  such  consequences  as  naturally  flow  from 
his  wrongful  act  or  negligence,  and  not  for  those  injuries  due  to  an 
intervening  and  intelligent  cause,  still,  if  a  plaintiff,  suffering  physi- 
cal harm  from  the  wrongful  act  or  omission  of  the  defendant,  calls  in 
good  faith  such  medical  attendance  as  it  is  reasonable  to  presume 
would  be  competent  to  effect  his  cure  or  restoration  to  health,  and 
the  physician  or  surgeon,  so  called,  by  erroneous  treatment  causes 
positive  harm,  the  plaintiff  shall  nevertheless  recover  in  the  action. 
At  the  same  time,  a  jury  being  the  arbiter  of  the  measure  of  damages, 
it  may  be  less  likely^  that  a  large  verdict  would  be  recovered  against 
the  original  tort-feasor  in  many  cases  than  against  the  physician,  if 
the  latter's  malpractice  could  be  established;  and  the  plaintiff,  having 
an  action  against  the  medical  attendant,  who  is  bound  to  exercise  at 
least  the  skill  and  knowledge  possessed  by  the  average  practitioner  of 
his  neighborhood,  may  often  find  him  a  more  desirable  defendant, 
especially  if  pecuniarily  responsible,  than  the  original  wrong-doer, 
although  the  latter  may  be  also  responsible  at  law. 

It  is  important  to  ascertain  if  there  has  been  deafness  or  a  discharge 
from  the  ear  before  or  at  the  time  of  the  alleged  injury,  and  if  so, 
whether  any  increase  of  the  trouble  was  caused  thereby.  This  is  a 
point  concerning  which  reliable  evidence  must,  in  many  cases,  be  en- 
tirely wanting  or  difficult  to  obtain,  since  both  may  exist  without  the 
patient's  knowledge.  Nor  is  the  testimony  of  others  in  this  regard 
always  competent,  for  both  teachers  and  parents,  where  children  are 
concerned,  may  have  no  suspicion  of  deafness  where  it  actually  exists, 
so  long  as  one  ear  remains  sound,  or  even  fairly  so.'  Where  the  ears 
have  been  pulled  and  boxed  repeatedly,  some  impairment  of  the  or- 
gan of  hearing  is  nearly  always  found,  and  often  very  pronounced  in 
degree.  But  where  the  injury  has  been  but  slight  and  confined  ta 
the  drum-head,  with  rapid  recovery,  hearing  is  usually  completely  re- 
stored. In  ascertaining  the  loss  of  hearing  power,  the  voice  is  the 
liest  test,  for  the  inability  to  converse  is  a  greater  detriment  than  not 
to  be  able  to  take  cognizance  of  other  sounds.  Malingering  may  be 
resorted  to  by  the  complainant,  but  unless  cleverly  done  is  not  liable 


WOUNDS    AND   INJURIES    OF    THE   DRUM-HEA.D.  187? 

to  deceive  the  expert  examiner.  This,  however,  is  a  device  seldom 
practised  unless  absolute  deafness  is  claimed,  a  result  seldom  follow- 
ing boxing  of  the  ears.  Where  great  deafness  is  claimed  to  result 
from  trauma,  the  drum-head  should  be  carefully  examined  for  evi- 
dence of  resulting  deformity,  using,  if  necessary,  a  magnifying  lens. 
The  question  of  permanent  injury  from  shock  is  likely  to  come  up 
in  some  cases.  Every  one  knows  that  falls  and  blows  upon  the  head 
often  give  rise  to  vertiginous  phenomena,  but  sei'ious  labyrinthine 
concussion  as  a  complication  of  ear-boxing  is  comparatively  rare, 
since  the  concussive  force  from  blows  with  the  hand  or  fist  is  broken 
by  the  drum-head,  thus  protecting  the  round  window.  Acute  inflam- 
mation of  the  middle-ear  consequent  upon  trauma,  as  from  other 
causes,  is  very  often  attended  with  vertigo.  In  cases  where  purulent 
inflammation  of  the  middle-ear  has  followed  trauma,  vertigo,  auto- 
phonia,  and  various  forms  of  tinnitus,  as  well  as  deafness,  may  re- 
main permanently.  It  is  well  to  remember  that  deafness  from 
chronic  catarrh  of  the  middle-ear  is  much  more  likely  to  be  found 
on  the  left  side. 

2.    INJURIES     TO    THE     DKUM-HEAD    FROM    BLOWS 
UPON   THE   EAR   WITH   MISSILES. 

Wounds  and  injuries  from  this  source  are  similar  to  those  produced 
by  boxing  the  ear.  They  may  be  due  to  the  impact  of  balls,  stones, 
and  other  objects,  or  to  swinging  doors  and  gates,  chains  and  the  like, 
striking  the  ear. 

Of  this  group  there  were  14  males  and  2  females.  Four  were  be- 
tween  3  and  18  years  of  age  ;  three  between  20  and  30  years  of  age  ; 
four  between  30  and  40  years  of  age  ;  four  between  40  and  50  years 
of  age,  and  one  was  53  years  old.  The  left  ear  was  affected  in  twelve 
cases,  the  right  in  three  cases. 

Five  were  injured  by  snow-balls ;  in  one  instance  the  ball  was 
frozen  solid  ;  in  one  it  was  wet  and  hard,  and  in  three  of  them  the 
snow  was  soft  and  part  of  it  became  impacted  in  the  concha  and 
meatus. 

When  the  external  auditory  canals  were  large,  the  injury  to  the 
drum -head  was  greatest. 

In  one  case,  the  ear  had  been  injured  25  years,  in  one  case  17  years, 
in  one  4  years,  in  two  cases  eleven  days,  and  in  one  seven  days  before 
they  applied  for  treatment. 

The  results  of  the  injuries  were  similar  to  those  arising  from  boxing 
^he  ear.     Pain  was  usually  experienced  immediately  or  soon  after  the 


188  WOUNDS    AND    INJURIES    OF   THE   DRUM-HEAD. 

accident.  In  two  instances  it  was  severe  for  more  than  a  week.  In 
one  case  there  was  inflammation  over  the  mastoid  extending  down  the 
neck,  an  abscess  finally  forming  behind  the  auricle.  Tinnitus  and 
dizziness  were  present  in  some  degree  in  nearly  all  of  the  cases.  One 
patient,  struck  with  a  snow-ball  on  the  ear  some  seventeen  years  be- 
fore, immediately  experienced  a  sound  like  a  steamboat  whistle  which 
lasted  for  fifteen  minutes  ;  there  was  no  pain,  but  the  noise  like  escap- 
ing steam  remained.  Examination  showed  a  large  opening  in  the 
drum-head  which  seemed  disposed  to  become  permanent.  This  per- 
foration was  triangular  in  shape  and  situated  in  the  posterior  segment; 
through  it  the  dry  inner  wall  of  the  drum  could  be  seen.  There  was^ 
furthermore,  a  small  blood-clot  in  front  of  the  umbo.  The  man  was 
a  pianoforte-tuner,  and  these  symptoms  interfered  very  much  with 
the  performance  of  his  duties.  A  disagreeable  perforation  whistle 
remained  for  some  time. 

In  some  of  these  eases  the  deafness  remaining  in  the  injured  ear 
was  very  great. 

Three  patients  were  struck  by  balls  of  various  kinds.  One  of  them 
was  walking  along  the  street  when  struck  upon  the  left  ear  by  a  base- 
ball. He  immediately  became  dizzy  and  a  "  hissing  "  noise  remained 
in  the  ear.  There  was  no  deafness  or  discharge,  but  in  twenty-four 
hours  a  perforation  whistle  was  noticed.  Examination  showed  a  large, 
irregularly  quadrilateral  opening  in  the  anterior  segment  of  the  drum- 
head. 

The  second  case  was  that  of  a  boy  who  was  struck  upon  the  left 
ear.  while  trying  to  catch  a  very  hard  baseball  coming  from  the  bat. 
He  reeled  over,  and  for  several  days  the  ear  pained  him  very  much. 
He  also  thinks  it  discharged  a  little.  It  has  ''buzzed  "  for  the  past 
year — in  fact,  ever  since  the  accident.  Some  deafness  is  present  and 
also  considerable  hyperaemia,  the  latter  due  to  the  entrance  of  water 
into  the  ear  "while  bathing  recently  in  the  sea. 

The  third  patient  had  been  struck  on  the  right  ear  by  a  large  rub- 
ber ball  a  week  before.  Pain  was  immediately  felt  and  throbbing  and 
buzzing  have  existed  ever  since.  There  is  a  large  perforation  below 
the  umbo,  across  the  upper  segment  of  which  a  band  of  organized 
tissue  has  formed  ;  the  lower  portion  of  the  opening  is  occupied  by  a 
blood-clot.  Restoration  having  thus  begun,  the  opening  in  all  proba- 
bility closed  soon  afterwards. 

One  patient,  aged  22  years,  was  struck  on  the  left  ear  with  a  stone 
nine  years  before.  This  accident  was  followed  by  a  discharge  from 
the  ear,  and  four  years  later  a  polypus  came  away.  One  week  ago,  the 
ear  became  acutely  inflamed,  the  process  extending  to  the  mastoid 


WOUNDS    AND   INJURIES    OF   THE    DRUM-HEAD.  189 

and  down  to  the  tissues  of  the  neck.  A  polypus  is  now  seen  present- 
ing at  the  orifice  of  the  canal. 

Another  patient,  an  Italian  laborer,  engaged  in  blasting  rock  for  a 
railroad  track,  was  struck  on  the  left  side  of  the  head  by  a  fragment 
of  rock,  which  ruptured  the  drum-head  and  nearly  detached  the  auri- 
cle.    A  most  persistent  discharge  remained. 

A  man,  50  years  old,  was  struck  upon  the  left  ear  with  the  frag- 
ment of  a  broom-handle  thrown  by  a  boy.  The  auricle  was  slightly 
contused,  and  for  eight  days  there  was  very  distressing  tinnitus.  The 
temporal  region  remained  sore  for  several  weeks.  These  symptoms 
were  due  to  the  impaction  of  a  mass  of  cerumen  by  the  blow  upon  the 
ear. 

Another  patient  came  Avith  the  statement  that  two  weeks  before, 
while  supporting  one  end  of  a  heavy  telegraph  pole,  the  other  end  was 
unexpectedly  dropped  from  the  shoulder  of  his  companion.  This 
caused  the  end  of  the  pole  he  was  holding  to  strike  against  his  right 
mastoid  process.  He  was  stunned  and  dizzy  for  a  few  minutes,  and 
for  three  days  the  whole  mastoid  region  was  much  swollen.  There 
was  immediate  tinnitus  like  "  escaping  steam  "  in  the  right  ear,  which 
still  continues.  Two  days  after  the  injury,  severe  pain  was  experi- 
enced for  a  couple  of  hours  below  the  lobe.  Examination  showed 
slight  hyperaemia  of  the  drum-head.  He  heard  loud  voice  only. 
This  patient  came  to  the  New  York  Eye  and  Ear  Infirmary,  and  was 
seen  but  once. 

The  following  injury  to  the  ear  occurred  to  a  patient  who  was 
riding  a  stumbling  horse,  when  the  animal  fell  upon  his  knees,  throw- 
jug  the  rider  over  his  head.  In  his  struggles  to  regain  his  feet,  the 
horse  stepped  upon  the  patient's  left  ear.  There  was  immediate  pain, 
followed  in  a  few  days  by  a  "  buzzing  ''  noise  and  throbbing  in  the  ear. 
Ten  days  after  the  injury,  which  happened  two  weeks  before  the  case 
was  seen,  the  patient  put  cottonwool  saturated  with  "  St.  Anthony^s 
Liniment "  in  the  meatus  and  thinks  some  of  it  entered  deeper  into 
the  ear.  The  ear  began  to  discharge  pus  the  day  before  he  came  for 
treatment.  Hears  loud  voice  only  in  the  affected  ear.  He  was  seen 
but  once. 

In  the  two  following  cases,  the  patients  were  struck  by  swinging  ob- 
jects. One  of  them  was  struck  three  days  ago  on  the  left  ear  by  an  office 
gate.  In  a  few  hours  severe  pain  set  in  in  the  affected  ear  and  still 
exists.  Soon  after  the  injury  acute  purulent  inflammation  of  the 
middle  ear  developed.  The  ear  had  been  syringed,  and  camphorated 
oil  introduced  before  he  came  for  treatment,  and  these  procedures 
seemed  to  have  aggravated  the  case.     The  other  case  was  that  of  a 


190  WOUND8    AND    INJURIES    OF    THE    DKUM-HEAD. 

man  who  was  struck  in  front  of  the  left  ear  by  a  swinging  iron  bar 
twelve  days  before.  He  was  stunned,  but  kept  on  with  his  work. 
There  exists  now  a  purulent  discharge  and  some  tinnitus,  but  deaf- 
ness is  slight. 

3.    INJURIES    OF  THE  DRUM-HEAD    FROM  FALLS    UPON 

THE    EAR. 

The  drum-head  may  be  injured  by  falls  upon  the  organ — the  effects 
being  similar  to  those  produced  by  blows  with  the  hand,  etc.  In  falls 
upon  the  head  from  a  great  height,  fracture  of  the  temporal  bone  is  to 
be  suspected.  The  latter  seldom  or  never  occurs  without  fracture  of 
the  other  portions  of  the  base  of  the  skull.  The  impact  in  falls  is 
liable  to  be  expended  upon  the  mastoid  in  some  cases  with  much  more 
force  than  from  blows  with  the  hand.  In  children  receiving  falls 
upon  the  head  involving  the  ear,  it  is  sometimes  difficult,  or  even 
impossible,  to  distinguish  between  fracture  of  the  base  of  the  skull 
involving  the  temporal  bone,  and  traumatic  meningitis. 

The  writer  has  the  records  of  thirty  cases  of  .injuries  of  the  oar  in 
consequence  of  falls — 17  males  and  13  females. 

Ten  of  them  at  the  time  of  the  injury  were  children  between  2  and 
6  years  of  age,  inclusive  ;  three  between  9  and  15  years  old  ;  nine  be- 
tween 20  and  40,  and  eight  between  41  and  59  years  of  age. 

The  right  ear  was  affected  in  15  cases,  the  left  in  11  cases;  in  1 
case  both  ears  were  affected,  and  in  3  cases  the  ear  affected  is  not 
given. 

A  large  number  of  persons  come  to  the  otologist  with  the  state- 
ment that  some  affection  of  the  hearing  organ  is  due  to  a  fall  upon 
the  ear.  Whilst  in  by  far  the  greater  number  of  these  the  trouble 
can  be  traced  to  other  causes,  it  cannot  be  doubted  that  to  trauma 
may  be  attributed  the  causation  in  many. 

In  11  of  the  cases  under  consideration,  the  injury  was  caused  by 
falling  down  upon  the  earth;  3  fell  down  upon  the  ground  while  in  a 
fainting  condition;  3  fell  down-stairs;  1  fell  down  from  the  second 
story  of  a  house;  1  fell  down  a  hatchway  on  board  ship;  1  fell  from 
a  ladder;  1  fell  from  a  tilting  plank;  1  fell  from  a  chair;  1  fell  upon 
the  water  in  diving  from  a  height;  3  slipped  and  fell  upon  the  ice;  1 
was  thrown  from  a  wagon;  and  3  struck  the  ear  against  resisting  ob- 
jects. 

Of  the  11  receiving  injuries  from  falls  to  the  earth,  8  were  children 
between  2  and.  9  years  of  age,  the  rest  being  adults.  The  accidents 
occurred  for  the  most  part  in  New  York  City,  the  falls  taking  place 


WOUNDS    AND    INJURIES    OF  THE    DRUM-HEAD.  191 

upon  the  hard  sidewalks,  curbstones,  or  pavements.  In  one  case,  the 
child  was  "  stupid  and  drowsy  "  after  the  accident,  and  had  a  serous 
discharge  from  the  ear  (probably  a  case  of  fracture  of  the  temporal 
bone).  In  another  case,  the  patient,  a  child  four  years  of  age,  fell 
upon  the  sidewalk  while  running,  and  three  days  afterwards  there  was 
fever,  and  the  "head  was  affected."  The  child  was  confined  to  its 
bed  for  a  month.  One  niglit  hearing  in  both  ears  was  lost  suddenly, 
but  during  the  following  three  months  it  returned.  This  was  prob- 
ably a  case  of  traumatic  meningitis. 

In  one  case,  the  patient  fell  down  upon  the  chin,  the  aural  injury 
occurring  in  consequence  of  concussion  imparted  to  the  temporo- 
maxillary  articulation. 

One  child,  two  years  of  age,  fell  upon  a  curbstone,  had  immediate 
pain  in  the  ear,  dizziness,  and  some  discharge  of  blood.  Several 
weeks  of  vigorous  syringing  and  medication,  before  coming  for  ad- 
vice, were  followed  by  a  chronic  purulent  inflammation  of  the  middle- 
ear  and  the  development  of  a  polypoid  growth.  The  inflammation 
extended  finally  to  the  mastoid  region. 

From  maltreatment  or  neglect  a  chronic  purulent  process  of  the 
middle-ear  was  established  in  several  cases.  Permanent  deafness  oc- 
curred in  a  number  of  instances. 

Of  the  three  cases  where  falls  were  due  to  fainting  attacks,  one 
struck  the  tragus  of  the  auricle  on  the  corner  of  a  table.  She  was 
dizzy  on  rising.  Inflammation  of  the  external  auditory  canal  and 
middle-ear  ensued;  tenderness  and  swelling  extended  down  the  neck. 
There  was  "  throbbing  "  and  deafness.  Another  woman,  after  severe 
vomiting,  fell  to  the  floor  insensible.  On  regaining  consciousness, 
the  right  ear  was  found  painful,  for  which  "carbolic  wash"  was 
prescribed.  This  probably  aggravated  the  case,  since  inflammation 
of  the  middle  ear  and  mastoid  cellules  developed;  there  was  tinnitus 
and  a  discharge. 

The  third  case  was  that  of  a  boy  sixteen  years  of  age,  who  fainted 
and  fell  down  after  cutting  his  finger.  He  was  unconscious  for  two 
hours.  The  ear  bled  at  the  time,  and  a  watery  discharge  was  soon 
established.  The  drum-head  was  fleshy-looking,  and  perforated  in 
the  posterior  inferior  quadrant.  There  was  pain,  tinnitus,  and  deaf- 
ness. A  free  purulent  discharge  followed,  which  ceased  in  seven 
months,  though  the  tinnitus  continued. 

Three  patients  fell  down  the  distance  of  one  flight  of  stairs.  One 
of  them  when  first  seen,  a  month  after  the  accident,  was  still  troubled 
with  pains,  giddiness,  and  noises  in  the  head.  Dizziness  was  greatest 
in  the  morning,  when  for  a  time  he  could  not  stand  upon  his  feet. 


192  WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 

Another,  seen  a  week  after  the  injury,  in  falling,  struck  upon  the 
left  side  of  his  head.  Blood  immediately  flowed  from  the  left  ear, 
but  ceased  on  the  second  day,  when  he  experienced  pain  and  tinnitus. 
There  was  no  deafness. 

The  third  patient  was  seen  one  week  after  the  injury.  He  had 
been  unconscious  for  some  time  after  the  fall.  Blood  gushed  from 
the  right  ear,  and  the  next  morning  the  external  auditory  canal  was 
filled  with  a  blood-clot.  There  was  no  pain  unless  traction  was  made 
on  the  auricle.  There  was  great  deafness.  The  drum-head  was  so 
much  inflamed  that  the  landmarks  could  not  be  recognized. 

One  patient  fell  down,  six  months  ago,  from  the  second  floor  of  a 
house,  striking  upon  the  right  side  of  the  head;  was  unconscious  for 
several  hours.  There  was  some  hemorrhage  from  the  right  external 
auditory  canal.  Deafness  was  not  observed  until  a  month  after  the 
accident.     The  child  is  otherwise  well. 

A  patient,  while  at  sea,  twenty  years  ago,  fell  a  distance  of  six- 
teen feet  down  a  hatchway.  Bleeding  immediately  took  place  from 
the  left  ear,  and  he  was  insensible  for  three  days.  Deafness  and  tin- 
nitus have  existed  ever  since.  The  canal  contains  exudative  matter. 
There  was  probably  a  fracture  of  the  temporal  bone. 

One  patient,  seven  months  ago,  fell  a  distance  of  four  feet  from  a 
ladder,  striking  against  the  right  ear.  There  was  immediate  tinni- 
tus, like  escaping  steam,  which  has  since  become  gradually  worse. 
The  drum-head  is  still  congested  in  the  anterior  segment,  the  prob- 
able seat  of  rupture.     Deafness  was  not  great. 

Another  patient,  three  weeks  ago,  fell  ten  feet  from  a  tilting  plank, 
striking  on  the  right  side  of  the  head;  was  dazed,  and  everything 
"  went  round. ^'  Ever  since  then  he  staggers  like  a  drunken  man. 
Has  tinnitus.  Hears  shouting  only,  and  this  gives  rise  to  pain. 
The  drum-head  had  healed  when  seen,  and  during  the  two  months 
the  patient  remained  under  observation  his  hearing  improved.  These 
symptoms  may  have  been  due  to  concussion  only. 

A  little  girl,  aged  3  years,  fell  from  a  chair  ten  days  ago,  striking 
the  left  side  of  the  head  upon  the  floor  ;  she  was  not  unconscious,  but 
blood  flowed  from  the  left  ear  for  an  hour.  There  was  but  little  pain 
or  deafness.  In  the  posterior  segment  of  the  drum-head,  a  small  red 
area  marks  the  seat  of  rupture. 

Another  patient,  a  man  26  years  of  age,  gives  a  very  interesting 
history.  At  the  age  of  10  years  he  "  took  a  header  "  off  a  dock  ten 
feet  above  the  water,  injuring  the  left  ear.  Fourteen  years  after  this, 
the  same  ear  was  injured  by  the  impact  of  a  heavy  wave  while  he  was 
bathing  in  the  surf  at  Coney  Island.     Six  months  ago,  when  about  to 


WOUNDS    AND    INJURIES    OF   THE    DRUM-HEAD.  193 

take  a  plunge  from  a  platform  four  feet  high,  he  slipped  and  fell, 
striking  upon  the  water  with  the  right  ear.  He  was  very  dizzy  on 
coming  to  the  surface  of  the  water  and  for  a  minute  could  see  nothing. 
He  experienced  noises  and  pains  in  the  ear  for  several  days  before  re- 
covery. There  is  but  little  deafness.  The  external  auditory  canals 
are  very  large.     Both  drum-heads  are  perforated. 

The  three  patients  who  slipped  and  fell  upon  the  ice  were  all  adults. 
One  came  five  months  after  the  injury.  While  skating  he  fell  upon 
the  back  of  the  head  and  was  stunned.  Tinnitus  was  at  once  re- 
marked, and  vertigo  and  deafness  still  exist.  The  left  drum-head  was 
ruptured.  The  other  two  cases  were  females ;  one  of  them  fell  heav- 
ily two  weeks  ago,  striking  the  ice  with  the  left  ear.  Autophonia  has 
been  very  distressing  ever  since.  The  drum-head  is  ruptured  across 
horizontally,  the  line  of  fracture  extending  under  the  umbo,  giving 
the  appearance  of  a  fracture  of  the  lower  end  of  the  malleus  han- 
dle. The  other  female  had  fallen  five  weeks  before,  striking  upon 
the  back  of  her  head.  Was  not  unconscious,  but  had  to  be  carried 
home.  There  was  marked  vertigo  and  complete  deafness  to  voice 
for  two  days.  These  symptoms  gradually  passed  off  in  two  weeks, 
though  some  deafness  remained.  Owing  to  the  injury  of  the  left 
drum-head,  a  "  rattling  "  noise  is  experienced  in  talking  and  singing. 

A  patient,  40  years  of  age,  was  thrown  from  a  wagon  seven  years 
ago,  striking  the  earth  with  the  left  side  of  the  head.  There  was  im- 
mediate pain,  and  numbness  and  tinnitus  have  continued  ever  since. 
The  drum-head  was  ruptured,  a  minute  perforation  remaining. 

Of  the  three  patients  striking  the  ear  against  resisting  objects,  one 
fell  against  a  safe,  rupturing  the  drum-head.  The  discharge  which 
followed  lasted  for  three  months,  and  deafness  of  the  right  ear  remains. 
One  struck  the  right  ear  against  the  key  of  a  door,  causing  a  discharge 
of  blood,  followed  by  a  purulent  discharge,  at  various  times,  for  the 
past  two  years.  There  is  occasional  pain  in  the  ear  and  great  deaf- 
ness. The  third  patient,  on  getting  out  of  bed  in  the  dark,  sixteen 
months  ago,  struck  the  right  ear  against  a  shelf.  He  was  unconscious 
for  a  time  and  afterwards  felt  dizzy  for  an  hour.  The  middle-ear  was 
much  inflamed,  the  inflammation  extending  to  the  external  auditory 
canal  and  mastoid  process.  The  pains  were  severe  for  a  month  (for 
a  part  of  this  time  he  was  unable  to  leave  the  house),  and  then  there 
was  a  discharge.  The  latter,  together  with  some  tinnitus  aurium, 
still  exists. 

It  appears  that  unconsciousness,  shock  or  concussion,  vertigo  and 
purulent  inflammation  of  the  middle-ear  are  much  more  common 
occurrences  after  falls  than  after  injuries  arising  from  blows  of  the 
13 


194  WOUNDS    AND    INJURIES   OF   THE   DRUM-HEAD. 

hand,  and  furthermore  that  some  doubt  must  exist  in  many  cases  in 
respect  to  the  extent  of  injury  of  the  temporal  bone — in  fact  it  would 
seem  probable  that  the  latter  is  fractured  more  frequently  than  is 
generally  supposed. 


4.  INJURIES  TO  THE  DRUM-HEAD  FROM  THE  VIOLENT 
IMPACT   OF   INTENSE   SOUNDS  OR  CONCUSSIVE 

FORCE. 

A.    THE   CONCUSSION  FROM    THE   BLAST   OF    PROJECTILES    OR    GREAT 

GUNS. 

That  the  ear  may  be  injured  by  the  violence  of  aerial  impact,  or 
concussive  force,  propagated  by  the  explosion  of  gunpowder,  has  been 
known  ever  since  the  introduction  of  explosives  in  military  warfare. 
Owing,  however,  to  the  obscurity  of  traumatic  lesions  of  the  drum  of 
the  ear,  or  of  its  deeper  parts,  and  the  limited  means  of  observation 
at  the  command  of  the  military  surgeon  in  the  field,  it  has  been  more 
difficult  to  study  these  injuries  than  most  other  wounds.  Such  was 
the  writer's  own  experience  at  least,  and  reference  to  the  literature  of 
the  subject  shows  that  the  opportunities  of  writers  on  'military 
surgery  were  probably  no  greater  in  this  respect.  It  is  a  fact,  more- 
over, that  from  the  suffering  occasioned  by  other  and  more  painful 
wounds  simultaneously  received,  together  with  the  bewilderment 
caused  by  nervous  shock,  aural  injuries  are  liable  to  be  entirely  over- 
looked. Indeed,  in  some  of  the  cases  about  to  be  described,  there  were 
serious  wounds  of  the  ear  of  which  the  wounded  men  themselves  had 
been  unconscious  up  to  the  time  of  examination,  several  weeks  after 
the  accident.  It  may  be  stated  here,  on  the  contrary,  that  after 
artillery  engagements  it  is  not  unusual  for  participants  to  fancy  that 
deafness,  due  to  other  causes  wholly,  has  been  produced  by  the  loud 
sounds  of  great  guns,  and  since  the  war  of  the  rebellion  applicants 
for  pensions  not  infrequently  present  their  cases  with  the  statement 
that  aural  disability  has  originated  in  this  manner. 

While  the  writer  was  recently  seeking  information  from  persons 
having  had  experience  in  the  field  or  on  shipboard,  especially  among 
army  and  navy  officers,  an  opportunity  quite  unexpectedly  presented 
itself  to  investigate  thoroughly  the  effects  of  concussive  force  on  the 
ears  of  a  number  of  men,  in  the  midst  of  whom  a  twelve-inch  mortar 
shell,  weighing  five  hundred  and  eighty-five  pounds,  and  containing 
a  bursting  charge  of  twenty-seven  pounds  of  rifle-powder,  was  acci- 


WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 


195 


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196 


WOUNDS    AND   INJURIES    OF   THE    DRUM-HEAD. 


dentally  exploded.     This  took  place  at  the  United  State  Ordnance 
Proving  Ground,  Sandy  Hook,  October  21st,  1886,  at  3:30  p.m.' 
The  effects  produced  by  the  bursting  of  this  shell,  both  as  regards 


© 


Fig.  31. 


A,  Sergeant  Abbott,  position  eight  feet  from  the  shell ;  B,  Private  King,  position  at  the  base  of 
the  shell;  C,  Lieutenant  Medcalfe,  position  at  the  side  of  the  shell;  D,  Corporal  Clark,  position 
fourfeet  from  the  shell;  £,  Corporal  Goodno,  position  twelve  feet  from  the  shell;  /^.Private 
Cunningham,  position  fifteen  feet  from  the  shell;  G,  Private  Cramer,  position  fifteen  feet  from 
the  shell;  H,  Mr.  Sinclair,  jHJsition  nineteen  feet  from  the  shell;  7,  Private  Bums,  position  nine- 
teen feet  from  the  shell;  J,  Corporal  Ingram,  position  sixteen  feet  from  the  shell. 

^  The  ordnance  officers  on  duty  at  the  time,  namely  Colonel  Mordecai,  Cap- 
tain Shaler,  and  Captain  Whipple,  kindly  oflFered  the  writer  every  facility  for 
investigation,  as  did  also  Colonel  Janeway,  of  the  Medical  Department,  U.  S. 
A.,  Post  Surgeon,  Governor's  Island. 


WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD.  197 

the  aerial  concussion  of  the  blast  and  the  distribution  of  fragments  of 
metal,  were,  of  course,  similar  to  those  produced  by  the  explosion  of 
projectiles  fired  from  great  guns  during  an  engagement;  and,  it  is 
hoped,  since  a  careful  study  of  wounds  of  the  ear  arising  from  this 
cause  have  never  been  reported,  so  far  as  known,  that  a  detailed 
account  of  the  conditions  of  the  organ  of  hearing,  found  to  exist  in 
the  persons  injured,  may  be  of  interest  to  both  medical  and  military 
men. 

The  scene  of  the  catastrophe,  as  shown  in  the  accompanying  cut 
(Fig.  30),  was  produced  from  a  photographic  view  taken  on  the  spot 
by  a  friend  of  the  author.  The  men  were  taken  in  about  the  same 
position  they  occupied  at  the  time  of  the  accident;  the  places  of  three 
of  them,  namely.  Lieutenant  Medcalfe  and  Private  King,  killed,  and 
Corporal  Goodno,  absent  in  hospital,  were  occupied  by  other  persons. 

The  diagram  of  the  twelve-inch  mortar,  gun  carriage,  and  platform 
(Fig.  31),  where  the  firing  was  taking  place,  was  designed  by  Captain 
Whipple;  the  facings  of  the  men  are  designated  by  arrows,  and  the 
direction  and  force  of  the  wind  at  the  time  is  also  shown.  The  dis- 
tance of  the  men  from  the  shell  which  exploded  will,  furthermore, 
be  found  in  the  text  accompanying  the  cut. 

As  an  immediate  effect  of  the  explosion.  Sergeant  Abbott  was  blown 
ten  feet  from  his  position.  Private  King  (who  was  closing  the  screw 
plug  in  the  base  of  the  shell  with  a  drift  and  hammer,  and  thus  ex- 
ploded it)  was  instantly  killed,  and  his  body  was  blown  fifty-five  feet 
away;  Lieutenant  Medcalfe,  who  was  standing  by  the  side  of  the  shell, 
was  blown  twenty-two  feet  and  died  in  thirty  minutes  ;  private  Clark 
was  blown  fifteen  feet.  The  other  six  men  kept  their  feet  during  the 
explosion.  Eight  men  thus  escaped  with  their  lives,  but  all  of  them 
were  more  or  less  injured  by  the  concussion,  and  some  of  them  re- 
ceived contused  wounds  or  were  burned  by  the  blast. 

The  three  men  first  described  below  were  examined  at  the  Post 
Hospital,  Governor's  Island,  October  31st,  where  they  had  been  sent 
for  treatment.  They  were  still  suffering  from  shock  and  contusions, 
but  able  to  walk  without  assistance  to  the  oflBce  where  the  examina- 
tions were  made. 

Case  1. — Sergeant  John  Abbott,  aged  34,  was  kneeling  on  right 
knee  and  toe  when  explosion  occurred,  presenting  right  ear  toward 
the  shell.  He  was  thrown  ten  feet  by  the  force  of  the  concussion, 
found  himself  upon  all  fours,  but  got  up  immediately  and  ran  some 
thirty  feet  before  looking  to  see  what  had  happened.  Noticed  that 
the  right  side  of  chest,  shoulder,  and  face  were  burned  by  the  blast. 
As  regards  his  hearing,  although  there  was  much  talking  and  shout- 
ing, he  could  hear  nothing  at  first.     He  was  much  confused,  but  had 


198  WODND8    AND   INJURIES   OF   THE    DRUM-HEAD. 

no  vertigo  or  pain  in  the  ears.  An  hour  after  the  accident,  however, 
the  deafness  was  found  to  be  confined  to  the  right  ear.  After  going 
te  bed,  blood  was  observed  on  the  pillow,  and  continued  to  trickle  from 
the  right  ear  for  two  or  three  hours,  when  it  ceased.  He  slept  but 
little.  Pain  has  been  experienced  in  the  injured  ear  on  blowing  the 
nose,  or  swallowing  only. 

Examination  of  ears. — Auricles  and  canals  healthy;  the  latter 
small. 

Eight  drum-head:  A  large,  irregularly  ovoidal  perforation  of  the 
drum-head  exists  in  the  posterior  segment;  it  is  bounded  anteriorly 
by  the  malleus  handle,  inferiorly  by  the  anuulus  tendinosus,  and  above 
by  the  membrana  flaccida.  There  is  a  narrow  margin  of  the  mem- 
brane between  'the  perforation  and  posterior  wall  of  the  external 
auditory  canal.  (This  opening  was  temporarily  occupied  by  a  dark 
crust,  probably  of  inspissated  muco-sanguinolent  matter.)  The  ante- 
rior segment  is  dull  and  fleshy-looking  (cicatricial?);  the  membrana 
flaccida  is  considerably  injected.  The  short  process  is  just  visible, 
pressing  out  as  a  lighter  point  in  the  drum-head. 

Left  drumhead:  Slightly  atrophic,  moist-looking,  and  opaque. 
Short  process  rather  prominent,  but  other  landmarks  somewhat 
faint. 


Fig.  88.— Abbott  :  Right  Drith-hrad. 

Hearing:  right  ear,  ordinary  voice  only;  left  ear,  low  voice  if  plainly 
spoken — distance,  eleven  feet. 

Patient  has  some  autophonous  phenomena,  the  voice  seems  lisping, 
and  for  three  or  four  days  past  there  has  been  tinnitus  aurium  re- 
sembling the  sounds  heard  in  a  shell  when  placed  to  the  ear.  Vision 
unaffected. 

November  27th. — Right  ear:  The  upper  portion  of  the  anterior 
segment  is  now  opaque,  slightly  vascular,  and  has  a  cicatricial  appear- 
ance; the  lower  portion  is  partly  cicatricial,  exposing  some  fibrous 
structure  extending  perpendicularly.  A  large,  dark,  partially  in- 
spissated blood-clot  yet  remains  on  the  lower  portion  of  posterior  seg- 
ment, extending  upward  in  front  of  the  malleus  handle;  repro- 
duction of  the  membrane  is  probably  taking  place  beneath  this  clot. 
The  clot  not  shown  in  diagram.  Patient  hears  low  voice  at  fifteen 
feet  plainly  in  both  ears,  but  when  several  persons  are  conversing  he 
cannot  follow  them.  His  voice  still  sounds  to  him  as  if  he  were  lisp- 
ing.    Has  occasional  tinnitus.' 

'  Abbott  was  not  again  seen  until  February  6th,  1888,  when  he  came  to  the 
writer's  oflSce.  He  was  then  complaining  of  having  had  pains  in  the  left  ear 
off  and  on  ever  since  the  accident,  but  especially  during  the  past  four  months. 
Five  weeks  before  he  had  been  in  the  Post  Hospital  for  four  days  with  the 
earache.      Says  he  feels  the  pain  in  the  ear  especially  in  damp  weather.     On 


WOUNDS    AND    INJURIES    OF    THP:    DKUM-HEAD.  199 

Case  2. — George  Clark,  aged  27;  entered  Governor's  Island  Hos- 
pital October  23d.  Was  standing,  when  the  explosion  took  place,  four 
feet  from  the  point  of  the  shell,  looking  at  King,  and  having  the  left 
ear  toward  the  missile.  He  was  thrown  fifteen  feet,  but  jumped  up 
at  once.  Was  much  confused  with  a  "dumb  feeling"  in  the  ears; 
first  running  away  from  the  scene,  and  then  returning.  He  staggered 
to  the  pump,  some  three  feet  distant,  and  felt  better  after  he  had 
taken  some  water.  He  has  been,  however,  unsteady  in  his  gait  ever 
since,  and  is  very  nervous  and  giddy.  He  was  employed  in  running 
errands  nearly  all  night.  Afterward  was  too  nervous  to  sleep.  He 
could  not  sleep  on  the  second  night,  but  on  the  third  night  was  given 
bromide  of  potassium,  which  has  been  continued  ever  since. 

Examinatio7i  of  ears. — Eight  ear:  The  posterior  segment  of  the 
drum-head  rather  opaque  and  there  is  at  about  the  centre  a  slightly 
injected  spot.  The  anterior  segment  is  fairly  brilliant,  with  good  cone 
of  light.  A  dark  line  extends  along  the  posterior  edge  of  malleus 
handle,  having  the  appearance  of  a  light-brown  crust.  This  might 
be  taken  for  a  shadow,  but  for  the  wrinkled  appearance  of  the  mem- 
brane about  its  centre,  the  folds  running  principally  up  and  down. 
Syringing  the  right  ear,  which  has  been  tried  once,  gives  rise  to  un- 
bearable pains  in  the  right  eye. 

Left  ear:  There  is  a  large  loss  of  substance  of  the  drum-head,  em- 


Fio.  33.— Clark  :  Left  Deum-head. 

bracing  most  of  the  posterior  segment  below  the  membrana  flaccida, 
extending  inferiorly  to  the  tympanic  ring,  then  curving  into  the  lower 
portion  of  anterior  segment,  and  through  which  the  inner  wall  of  the 
tympanum  can  be  seen.  The  landmarks  afforded  by  the  malleus 
handle  are  not  visible,  but  the  whole  membrana  flaccida  and  the  upper 
portion  of  the  anterior  segment  of  the  membrana  vibrans  has  a  thick- 
ened, macerated,  and  retracted  look.     There  is  a  pulsating  bubble, 

examination,  the  left  lower  second  molar  is  found  to  be  in  a  very  carious  state, 
the  pulp  being  probably  exposed.  The  left  upper  six-year  molar  is  denuded 
on  the  palatal  surface.  Patient  never  complains  of  toothache.  Examination 
of  the  right  (injured)  drum-head  shows  the  anterior  segment  to  be  lustreless, 
and  very  irregular  in  front  of  the  unibo  ;  scattered  light  spot.  The  posterior 
segment  is  also  lustreless.  The  fibrous  layer  is  more  or  less  exposed.  The 
condition  of  the  left  drum-head  has  not  changed  from  that  already  described 
above. 

Patient  says  his  hearing  is  not  as  good  as  formerly,  and  has  become  con- 
siderably worse  during  the  past  four  months.  He  cannot  hear  the  word  of 
command  in  firing,  and  relies  on  others  for  a  signal,  in  pulling  the  lanyard. 
On  examination,  ordinary  voice  is  heard  in  both  ears  at  eleven  feet  distance. 
The  general  health  of  the  patient  is  excellent,  but  he  is  worried  about  his 
hearing. 


200  WOUNDS   AND   INJURIES   OF   THE    DRUM-HEAD. 

affording  a  light-reflex  in  the  anterior-inferior  portion  of  the  tympa- 
num, and  another  posteriorly. 

Hearing:  Eight  ear,  low  voice;  left  ear,  only  low  voice  at  eleven 
feet  distance. 

A  small  amount  of  blood  trickled  from  left  ear  the  night  of  the 
injury;  there  is  now  discharge  of  muco-purulent  matter.  Pain  has 
been  experienced  in  the  lef  c  temporo-maxillary  space.  The  ear  has 
been  syringed  several  times  daily  with  a  pump-syringe,  and  the  mas- 
toid process  was  blistered  three  days  ago.  For  twenty-four  hours 
after  the  injury  mastication  was  painful.  Eructations  also  gave  rise 
to  pain.  His  own  voice  is  autophonous,  and  sounds  "far  off"  to 
him.  Patient  has  become  highly  neuropathic,  and  says  he  has 
**gone  all  to  pieces."  He  can  scarcely  stand  to-day,  and  seems  to  be 
getting  weaker.  Complains  also  of  left  eye;  says  it  is  "blurred." 
Both  pupils  are  large,  but  respond  to  light.  There  is  twitching  at 
the  inner  canthus  of  the  left  eye  and  above  the  angle  of  the  jaw. 

Patient  complains  of  pain  through  temples,  with  throbbing  sensa- 
tion. His  pulse  is  weak  and  irregular.  There  is  a  noise  in  the  left 
ear  resembling  that  of  a  "steamboat." 

November  21st. — He  has  been  on  duty  at  Sandy  Hook  for  past  ten 
days.  His  left  arm  and  leg  feel  numb  unless  he  is  exercising,  and 
especially  at  night.  He  is  feeling  somewhat  stronger.  Complains  of 
no  vertigo,  but  of  much  dull  pain  in  temporal  regions,  which  is  in- 
creased by  the  firing  of  great  guns.  Cold  air  causes  pains  in  the 
ears,  especially  in  the  left,  and  patient  thinks  that  the  left  auricle  is 
colder  than  the  right.  The  right  ear  is,  however,  healthy.  The  left 
ear  has  healed,  and  the  inflammation  and  discharge  have  ceased.  The 
perforation  remaining  is  as  large  as  when  first  seen,  and  shows  no 
tendency  toward  closing.  The  malleus  handle  is  scarcely  distinguish- 
able. There  is  pain,  at  times,  in  the  ear,  but  no  tinnitus.  He  has 
still,  however,  tinnitus,  resembling  escaping  steam,  in  the  right  ear. 
Introduction  of  a  speculum  into  the  left  ear  causes  tears  to  flow  from 
left  eye,  which  also  feels  irritated.  When  patient  uses  his  eyes  in 
reading,  etc.,  the  left  gets  "blurred,"  he  says,  and  "  weak." 

Hearing:  Left  ear,  loud  voice  only;  right  ear,  low  voice,  at  eleven 
feet  distance. 

Patient  becomes  confused  when  several  persons  are  conversing. 

November  27th. — Patient  is  now  improving,  and  feels  stronger. 
He  is  less  nervous  also.  In  the  left  ear  the  parts  are  clearing  up, 
but  the  perforation  is  unchanged.' 

Case  3. — Corporal  Walter  Goodno,  aged  34,  had  just  picked  up  a 
handspike,  and  walked  away  from  the  shell.  Thought  a  keg  of  pow- 
der on  his  right  had  exploded,  and  tried  to  get  away.  His  ankle  was 
hit,  hat  torn  to  pieces,  and  he  received  a  contused  wound  of  the 

^Captain  Whipple  writes,  December  22d,  1886:  "  I  am  sorry  to  say  that  I 
hear  Corporal  Clark,  whom  I  had  transferred  back  to  Springfield,  is  not  doing 
well.  His  '  hearing '  is  getting  worse,  and  he  seems  to  have  lost  his  grip." 
Subsequently,  however,  Clark  became  much  better. 


WOUNDS    AND    INJURIES    OF   THE    DRUM-HEAD.  201 

scalp,  just  below  the  occipital  protuberance.  Patient  had  his  left  ear 
turned  nearly  toward  the  shell  at  the  time  of  its  explosion.  He  had 
autophonia  at  once,  could  hardl}^  hear  his  own  voice;  but  could  dis- 
tinguish pretty  well  what  others  were  saying,  in  the  right  ear.  Im- 
mediately after  the  injury  there  was  a  great  ringing  in  the  left  ear. 
Patient  says  he  felt  something  (which  he  fancies  was  blood)  drop 
down  ''into  the  throat  from  the  head"  about  an  hour  afterward. 

Examination  of  Ears. — Left  ear:  At  the  inner  end  of  the  canal  the 
cutis  is  dry,  white,  and  exfoliating,  being  covered  with  a  light  coat- 


FiG.  84.— GooDNo:  Left  Drum-head. 

ing  of  boracic  acid  and  iodoform  in  powder.  Almost  the  entire  por- 
tion of  the  drum-head,  constituting  the  membrana  vibrans,  appears 
more  or  less  disorganized;  the  posterior  portion  is  missing,  leaving  a 
ragged  edge,  and  the  anterior  portion  has  a  bruised,  fleshy  look. 
The  malleus  handle  is  very  prominent. 

Right  ear:  Slight  injection  along  malleus  handle.  A  large  circular 
area,  occupying  almost  the  entire  upper  portion  of  the  posterior  seg- 
ment, is  of  recent  cicatricial  formation,  with  uneven,  depressed,  and 
lustreless  surface.  Behind  this  can  be  seen  the  inferior  portion  of  the 
long  process  of  the  incus.  On  the  umbo  is  a  small,  dark  blood-clot. 
Two  parallel  folds  of  the  membrane,  resembling  cords,  run  from  the 
umbo  forward  and  downward  to  the  margin  of  the  drum-head.  The 
area  between  these  is  occupied  by  disorganized  substance.  Both  ex- 
ternal auditory  canals  are  large. 

Hearing:  Eight  ear,  low  voice,  if  plain;  left  ear,  ordinary  voice,  if 
plain,  at  twelve  feet  distance.  Patient  still  has  autophonia.  The 
pulse  is  feeble,  and  rather  frequent. 


Fig.  35.— Goodno  :  Right  Drum-head. 

December  6th. — Patient  has  recovered,  and  will  report  for  duty. 
The  right  ear  shows  a  minute,  dark,  and  depressed  cicatrix  at  umbo. 
Below  this,  occupying  nearly  the  entire  area  of  the  lower  segment  of 
the  drum-head,  is  a  large,  circular  perforation  (see  Fig.  35),  where 
there  was  broken-down  tissue  before.  No  inflammatory  symptoms 
remain,  and  the  drum  is  cured.  In  the  left  ear  nearly  all  of  the  drum- 
head is  absent,  and  the  denuded  malleus  handle  hangs  down  in  front 


202  WOUNDS    AND   INJURIES   OF   THE    DRUM-HEAD. 

of  the  inner  wall  of  the  tympanum  i7i  situ.^  The  anterior  edge  of 
the  round  window  and  the  incudo-stapedial  joint  is  exposed  to  view. 
All  the  parts  have  a  whitish,  dry  appearance.  All  discharge  from 
the  ears  has  eased.  Syringing  or  probing  the  left  ear  causes  a  sensi- 
tive impression  in  the  left  eye  and  lower  part  of  the  larynx. 

Hearing:  Left  ear,  ordinary  voice;  right  ear,  lowest  voice,  at  fif- 
teen feet  distance.  Watch  heard  in  left  ear  only  on  contact;  in  right, 
at  thirty-three  inches.'  The  extent  of  sloughing  in  the  membranes 
in  this  case  is  remarkable.  The  great  amount  of  hearing  for  the 
voice  is  also  notable,  and  quite  in  contrast  to  the  poor  hearing-power 
for  the  watch. '^ 

The  following  persons  Avere  examined  at  Sandy  Hook,  November 
27th,  1886,  over  five  weeks  after  the  accident: 

Case  4. — Mr.  Allen  G.  Sinclair,  machinist,  aged  62  years;  has 
been  in  the  employment  of  the  United  States  Government  for  some 
thirty-seven  years,  twenty-four  of  which  have  been  passed  in  the 
Ordnance  Department.  He  has  been  testing  guns  for  twenty  years, 
but  has  never  experienced  unpleasant  sensations  or  injury  of  the  ears 
from  this  occupation.  At  the  time  of  the  explosion,  the  patient  was 
standing  about  nineteen  feet  from  the  point  of  the  shell,  and  facing 
it.  At  first  he  was  dazed  for  some  moments,  but  does  not  think  he 
was  thrown  down.  His  hat  was  blown  off.  He  had  no  pain  in  the 
ears,  but  a  noise  in  both  resembling  escaping  steam.  This  still  con- 
tinues, but  is  less  severe.  Of  late  he  has  felt  pulsations  in  the  ears, 
mostly  in  the  left.  These  are  variable,  scarcely  ever  occurring  before 
about  3  o'clock  a.m.,  when  he  fancies  they  wake  him  up.  His  ears 
have  felt  '*  dumb  "  from  the  first,  at  times,  and  his  own  voice  is  au- 
tophonous  and  seems  distant  to  him.     No  vertigo. 

Examination  of  ears. — Eight  ear:    The  malleus  handle  has  a  light 


Fig.  36.— Sinclaie:  Right  Drum-head. 

brown  appearance,  and  behind  it  lie  some  inspissated  blood-crusts. 
A  cicatricial  area  extends  from  the  anterior  superior  border  of  the 
tympanic  ring  downward,  and  terminates  in  a  transverse  band  of 
thicker  tissue  below.  Underneath  this  band  there  is  a  large  loss  of 
substance  in  the  membrane,  and  under  this,  below  the  umbo,  extend- 

^  The  diagrams  of  the  drum-heads  in  this  case,  as  in  the  others,  represent  the 
appearance  of  the  parts  when  last  seen. 

*  Corporal  Goodno  suffered  a  relapse  in  respect  to  the  wound  at  the  occiput, 
which  had  healed  but  slowly,  and  on  return  to  the  hospital  a  small  fragment 
of  shell  was  removed  from  the  wound.  After  this  recovery  was  rapid.  This 
patient  was  heard  from  in  December,  1887,  and  was  then  reported  as  perfectly 
well  and  strong. 


WOUNDS    AND    INJURIES    OF    THE    DKUM-HEAD.  203 

ing  into  the  lower  portion  of  the  posterior  segment,  is  another  area  of 
cicatricial  tissue,  due  to  reproductive  growth.  The  denuded  short 
process  marks  the  termination,  posteriorly,  of  the  band  above  men- 
tioned. 

A  small  crust,  consisting  of  epithelium  and  inspissated  blood,  which 
has  worked  ofE  from  the  wound  of  the  drum-head,  lies  on  the  poste- 
rior wall  of  canal.  The  parts  have  healed  up  entirely,  and  are  free  of 
any  injection.  Through  the  large  perforation  the  inner  wall  of  the 
tympanum  is  visible. 

Left  ear:  A  blood-clot  occupies  most  of  the  posterior  segment  of 
the  drum-head,  which  is  elsewhere  fairly  brilliant.  At  the  junction 
of  the  inner  end  of  canal  and  posterior  edge  of  the  membrane,  and 
behind  the  clot,  there  is  a  small  ulcerous  surface  covered  with  a  rather 
loosely  attached  scab,  the  seat  of  a  perforation  probably.  Both  of 
the  external  auditory  canals  and  drum-heads  are  large,  and  this  may 
account  for  the  great  amount  of  injury.  The  ears  have  received  no 
treatment. 

Hearing:  Left  ear,  ordinary  voice  only,  at  ten  feet;  not  as  clearly 
in  the  right. 

December  13th. — Right  ear:  The  crust  of  epithelium  and  inspis- 
sated blood,  which  was  described  as  working  off  the  drum-head  on  to 
the  posterior  wall  of  canal,  can  be  picked  off.  The  small  blood-clot 
behind  the  short  process  has  become  detached,  leaving  a  reproduced 
dermic  layer  beneath.  The  perforation  has  become  smaller,  and  its 
circumference  looks  as  if  it  would  contract  still  further. 

Left  ear:  Membrana  tympani  cleared  up  entirely.  The  crust  on 
the  drum-head,  near  the  wall  of  canal,  has  worked  off  on  the  canal, 
and  can  be  easily  removed.  The  blood-clot,  which  occupied  almost 
the  entire  posterior  segment  of  the  drum-head,  is  loose,  and  can  be 
easily  removed  with  the  forceps.  Beneath  this  crust,  doubtless  the 
seat  of  a  perforation,  the  membrane  has  healed  up  entirely. 

Hearing:  Left  ear,  low  voice;  right  ear,  loud  voice,  at  fifteen  feet 
distant.  Watch  pressed  against  tlie  ears  not  heard  at  all.  Patient 
hears  the  noises  in  the  streets  of  wagons,  etc.,  like  a  low,  rumbling, 
unaccustomed  sound.  He  has  no  nausea,  vertigo,  etc.,  and  feels  very 
healthy  and  strong.' 

Case  5. — Private  Michael  D.  Burns,  24  years  of  age,  was  standing 
-about  eighteen  feet  away,  and  was  dumfounded  by  the  explosion,  felt 
stunned  and  dizzy,  and  had  ''  buzzing"  noise  in  both  ears. 

Examination  of  ears. — Both  canals  are  of  medium  size. 

'  Sinclair  was  seen  at  the  writer's  office  in  December,  1887.  He  was  then 
feeling  well  and  strong,  but  said  that  cold  weather  affected  him  more  than  for- 
merly. The  perforation  in  right  drum-head  has  healed,  but  the  area  of  thin 
tissue,  as  shown  in  the  illustration,  still  exists.  The  left  drum-head  is  whole, 
and  of  rather  cloudy  appearance.  Hearing  has  improved.  He  hears  low  ordi- 
nary voice  at  twenty  feet,  also  at  ten  feet,  in  both  ears,  but  slightly  better 
in  right.  He  has  some  difficulty  in  liearing  conversation  carried  on  by  three  or 
four  persons,  especially  in  a  warm  room. 


204  WOUNDS    AND    INJURIES   OF   THE    DRUM-HEAD. 

Right  ear:  There  is  a  marked  vascular  condition  about  the  superior 
portion  of  the  drum-head,  and  extending  down  along  the  malleus 
handle.  The  drum-head  has  a  general  humid  appearance,  and  there 
is  a  beginning  opacity  just  in  front  of  the  umbo.  There  is  a  small 
cicatrix,  with  some  fibrous  lines,  in  lower  portion  of  posterior  seg- 
ment. Since  this  ear  was  more  exposed  than  the  left,  the  abnormali- 
ties seen  point  to  extensive  injury  followed  by  almost  complete 
restoration.  " 


Fig.  37.— Burns  :  Left  Drum-head. 

Left  ear  :  The  drum-head  has  a  somewhat  humid  appearance,  due 
to  catarrhal  inflammation  of  the  middle-ear.  There  is  a  recent  per- 
foration in  the  posterior  segment  near  the  edge  of  drum-head.  This 
is  partly  concealed  by  a  crust,  and  gives,  on  inflation,  a  whistling 
sound. 

Hearing  :  Right  ear,  ordinary  voice ;  left  ear,  lowest  voice,  at  fif- 
teen feet  distance.  Watch  heard  at  /^  inches  in  the  right  ear,  and  at 
^  inches  in  the  left.  This  man  had  both  auricles  frozen  two  years 
ago,  while  out  on  the  plains.* 

Case  6. — Private  Joseph  Cunningham,  23  years  of  age,  very  tall 
and  slender.  After  the  accident  patient  did  not  take  cognizance  of 
anything  for  a  few  minutes,  and  was  dizzy  for  two  days  afterward. 
Has  been  troubled  in  both  ears  since  the  explosion,  especially  in  the 
right,  which  was  constantly  painful  for  over  a  week,  and  is  occasion- 
ally so  now.  He  experienced  tinnitus  aurium,  which  has  not  entirely 
ceased  yet.  His  voice  was  autophonous  and  sounded  hoarse  and 
unnatural  to  him  in  both  ears  for  four  days. 

Examination  of  ears. — Right  ear:  The  drum-head  is  imperfectly 
developed  ;  it  is  transparent  (as  in  cases  of  cicatricial  reproduction) 
and  lacks  brilliancy.  The  short  process  protrudes  unduly.  There  is 
a  crust  on  the  margin  of  the  posterior  segment,  and  a  slight  opacity 
below  the  umbo. 

Left  ear  :  The  same  general  appearances  of  the  drum-head  are 
present  as  in  the  right  ear.     The  outlines  of  the  malleus,  however^ 

'  Private  Burns  was  seen  at  the  writer's  oflSce,  February  19th,  1888.  He  said 
then  that  he  was  very  sensitive  to  loud  noises  in  the  right  ear,  and  after  firing 
had  pain  in  the  ear  and  head.  He  also  experiences  tinnitus  like  "  steam"  and 
"  jumping"  sounds  in  the  right  ear  when  lying  upon  it  at  night.  Examina- 
tion shows  the  right  drum-head  to  be  red  about  the  upper  posterior  quadrant. 
The  left  drum-head  shows  no  redness.  There  is  a  lack  of  brilliancy  in  both 
membranes.  The  first  upper  left  bicuspid  is  a  mere  shell,  and  there  is  much 
tartar  on  the  upper  and  lower  front  teeth.  There  is  also  a  tendency  to  ozsena. 
Hears  low  voice  in  both  ears  at  twenty  feet. 


WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD.  205 

are  much  more  prominent.  The  long  process  of  the  incus  and  its  at- 
tachment to  the  stapes  is  very  plainly  seen  through  the  drum-head. 
Just  posteriorly  to  the  short  process  a  small  area  of  the  membrane  is 
much   thinner  than  elsewhere  and  seems  sunken. 

Notwithstanding  these  abnormalities,  thepatient  gives  no  history  of 
previous  ear  trouble,  and  there  is  a  strong  probability  that  the  appear- 
ance is  due  to  reproduction  succeeding  almost  complete  destruction  of 
both  drum-heads  from  the  explosion. 

Hearing  :  Eight  ear,  low  voice,  with  difficulty ;  left  ear,  lowest 
voice,  at  fifteen  feet  distance. 

Case  7. — Private  Thomas  Cramer,  aged  39,  was  standing  with  back 
toward  shell,  but  the  right  ear  was  a  little  more  exposed  than  the 
left ;  felt  a  stinging  sensation  from  the  concussion  "  all  the  way  up 
the  left  side  from  the  foot  to  the  ear."  Has  felt  nothing  since.  The 
ears  were  apparently  uninjured.  It  is  difficult  to  account  for  the  es- 
cape of  the  ears  from  injury  in  this  case. 

Hearing :  At  fifteen  feet  distance,  lowest  voice  in  both  ears,  but 
best  in  right. 

Case  8. — Corporal  Ingram,  32  years  of  age,  felt  stunned  for  a 
minute  or  so,  but  had  no  pain  or  vertigo  ;  in  fact,  had  no  aural  symp- 
toms whfevtever. 


Fig.  38.— Ingram  :  Ljeft  Drum»head. 

On  examination  it  was  found  that  both  ears  contained  considerable 
soft  cerumen.  Patient  had  accumulation  of  wax  syringed  from  both 
ears  in  1883.  As  no  symptoms  of  injury  to  the  hearing  organs  had 
appeared,  it  was  thought  probable  that  the  presence  of  this  accumu- 
lation of  cerumen  had  been  the  means  of  protecting  the  drum-heads 
from  the  injurious  effects  of  the  explosion.  This,  however,  does  not 
appear  to  have  been  the  case.  When  the  cerumen  was  removed  a  few 
days  later,  it  was  found  that  the  quantity  was  not  sufficient  to  occlude 
the  canals.  The  right  and  most  exposed  drum-head  looked  well  ;  it 
was  probably  protected  from  the  concussion  by  the  heavy  wooden 
structure  upon  which  the  mortar  was  mounted.  Behind  the  wax, 
however,  in  the  left  ear,  which  was  turned  from  the  shell,  was  a  quan- 
tity of  inspissated  purulent  matter  and  epithelium.  When  this  was 
removed,  the  drum-head  was  found  to  be  red  and  angry-looking,  and 
the  landmarks  were  not  seen.  Syringing  produced  a  feeling  of  faint- 
ness  and  nausea. 

Hearing  :  Left  ear,  ordinary  voice  only ;  right  ear,  low  voice  at  fif- 
teen feet  distance. 

December  4th. — There  has  been  no  discharge  from  the  left  ear,  and 
parts  have  cleared  up  slightly,  showing  great  arrest  of  development, 
the  short  process  and  posterior  fold  being  very  prominent;  otherwise 


206  WOUNDS    AND    INJURIES    OF   THE    DEUM-HEAD. 

the  landmarks  are  hardly  distinguishable.  The  entire  membrana. 
vibrans  is,  apparently,  in  a  necrotic  state,  indistinguishable  from  the 
inner  wall  of  the  tympanum.  A  very  thick  desquamative  collection 
lies  at  the  site  of  the  anterior  inferior  segment. 

December  31st. — There  has  been  no  discharge  or  pain,  and  the 
parts  are  dry.  It  can  be  seen  that  the  entire  membrana  vibrans  has 
been  destroyed,  excepting  a  thin  edge  remaining  attached  to  the  pos- 
terior wall  of  the  tympanum.  Patient  thinks  hearing  in  the  left  ear 
has  improved.      He  has  no  tinnitus,  vertigo,  or  ausea. 

Hearing  :  Left  ear,  low  voice  at  fifteen  feet  distance  ;  as  tested  by 
Konig's  rods,  fifty  thousand  vibrations  per  second  perceived  in  both 
ears. 

The  diagrams  of  the  drum-heads  injured  were  drawn  by  Dr.  0.  J. 
Colles,  The  dark  shading  marks  the  extent  of  loss  of  substance  in 
each  case  ;  the  lighter  indicates  the  presence  of  cicatricial  tissue.  In 
the  case  of  Cunningham  no  diagram  is  given,  since  the  parts  were 
probably  almost  entirely  reproduced. 

Remarks. — As  might  have  been  expected,  the  immediate  effect  of 
the  severe  concussion  caused  by  the  blast  of  the  explosion  just  de- 
scribed was  dumbfounding  in  the  extreme,  so  far  as  most  of  the  per- 
sons in  the  immediate  vicinity  were  concerned.  The  mental  confusion 
which  ensued  in  some  of  the  cases  lasted  a  long  time,  and  in  one  in- 
stance, that  of  Corporal  Clark,  it  is  doubtful  if  complete  recovery 
ever  takes  place. 

In  some  of  the  cases  the  absence  of  prominent  symptoms  of  injury 
of  the  ear,  such  as  pain  in  the  organ,  tinnitus,  deafness,  or  discharge, 
was  noticeable.  Soldiers  are,  however,  as  a  rule,  accustomed  to  en- 
dure hardship  without  complaint,  and,  in  fact,  all  insensitive  persons 
are  liable  to  overlook  ear  disease  until  incapacitated  to  perform  their 
work.  It  was  only  after  persistent  inquiries  were  made  that  some  of 
these  persons  would  admit  that  they  had  suffered  any  injury  of  the 
ear. 

The  writer  has  obtained  some  facts  in  conversing  with  officers  who 
served  during  the  war  of  the  rebellion,  which  may  be  of  interest  here. 
Commander  Eobeson,  at  the  naval  attack  on  Fort  Fisher,  found  that 
the  continued  explosion  of  fifteen-inch  shell  at  close  quarters  gave  rise 
to  very  disagreeable  ringing  in  the  ears,  which  finally  benumbed  the 
hearing  sense  so  much  that  he  could  not  hear  an  order  given  on  deck 
for  several  days;  the  disability,  however,  was  but  temporary.  Dr. 
Delavan  Bloodgood,  Medical  Director  U.  S.  N.,  informed  the  author 
of  a  case  where  deafness  was  said  to  be ''from  concussion  of  the 
cannon"  in  an  action  on  Lake  Champlain,  July  3d,  1813.  The  case 
was  that  of  Captain  Sawyer,  U.  S.  N.,  who  was  a  midshipman   on 


WOUJSIDS    AND    INJURIES   OF    THE    DRUM-HEAD.  207 

board  the  sloop  Eagle,  which  was  sunk  by  the  British  flotilla,  aided 
by  troops  on  the  shore.  The  engagement  lasted  four  hours;  and 
the  captain  was  afterward  taken  to  Halifax  and  confined  on  board 
a  prison-ship  over  seven  months.  It  is  probable  that  exposure  subse- 
quent to  the  action  very  much  increased  what  might  have  been  but  a 
temporary  difficulty.  On  the  cessation  of  the  retaliatory  hostage 
system,  he  was  immediately  ordered  to  the  Constitution,  and  after- 
ward served  in  the  Brazilian,  Pacific,  West  Indian,  and  Mediterranean 
squadrons,  and  was  finally  surveyed  and  condemned,  on  account  of 
deafness,  in  1822. 

The  writer  is  in  receipt  of  a  communication  from  Medical  Director 
Henry  0,  Mayo  (retired),  U.  S.  N.,  giving  his  own  experience  as  to 
the  effect  on  the  ear  of  the  concussion  of  great  guns,  which  is  of 
much  interest,  as  showing  the  effect  of  repeated  injuries.  He 
says:  "I  first  felt  the  effects  of  concussion  from  big  guns  in  the 
summer  of  1861,  on  board  the  frigate  Savannah,  while  engaged  in  a 
scrimmage  with  some  rebel  gunboats  at  the  mouth  of  the  James 
River.  As  the  affair  promised  to  be  of  a  bloodless  character,  from 
the  respectful  distance  kept  by  the  enemy,  I  seated  myself  in  the 
bridle-porb,  on  the  gun-deck,  to  watch  the  performance.  My  hearing 
was  quite  impaired  for  a  day  or  two,  but  in  a  short  time  the  effects  of 
concussion  passed  off  entirely. 

"  Just  at  the  close  of  1864  I  was  attached  to  the  U.  S.  S.  Powhat- 
tan,  of  Admiral  Porter's  fleet,  and  was  engaged  five  days  (three  at 
one  time  and  two  at  another)  in  the  bombardment  of  Fort  Fisher, 
and  the  other  batteries  at  the  entrance  to  Wilmington.  Having  oc- 
casion to  go  on  deck  at  times  during  the  action,  I  could  only  do  so  by 
the  cabin  companion-way,  which  was  but  a  few  feet  from  the  eleven - 
inch  pivot  gun.  This  chanced  to  be  discharged  two  or  three  times, 
just  as  my  head  was  about  on  a  level  with  it,  going  up  or  down  the 
hatch,  and  the  concussion  was  tremendous.  Once  1  thought  the  gun 
had  burst,  and  taken  my  head  along  with  it  !  Upon  reaching  home, 
a  month  or  two  afterward,  I  found  the  hearing  of  the  left  ear  much 
impaired,  but  the  right  still  served  me  so  well  that  I  was  enabled  to 
continue  my  ordinary  duties  on  the  active  list. 

"  In  the  early  part  of  1870,  I  went  to  China  as  surgeon  of  the 
Asiatic  fleet.  During  this  cruise  I  was  exposed  for  one  entire  day  to 
the  concussion  of  big  guns  engaged  at  target-firing  on  board  the  flag- 
ship Colorado.  This  gave  the  coup  de  grace  to  the  hearing  of  the 
left  ear,  and  still  further  impaired  that  of  the  right.  In  1875,  I  was 
retired  on  account  of  deafness." 

Dr.  Mayo  is  of  the  belief  that  the  cause  of  the  defectiveness  lies  in 


208  WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 

the  transmitting  mechanism  of  the  middle  ear,  and  not  in  the  inner 
ear  or  auditory  nerve  tract.  The  Eustachian  tube  of  his  left  (worst) 
ear  has  always  seemed  abnormally  pervious,  luhile  the  right  was 
considerably  obstructed.  He  cannot  hear  the  loudest-ticking  watch 
pressed  against  the  left  ear,  and  only  faintly  in  the  right,  but  can 
converse  pretty  well  with  one  person  at  close  range,  who  speaks  slowly 
and  distinctly. 

It  would  seem  difficult,  in  cases  where  chronic  catarrh  of  the  mid- 
dle ear  already  existed,  to  determine  the  exact  amount  of  injury  due 
to  this  cause  and  to  concussion,  respectively.  It  is  probable  that 
whererigidity  or  fixation  of  the  transmitting  mechanism  existed  from 
catarrh,  the  ear  would  thus  be  made  more  sensitive  to  concussion. 
On  the  other  hand,  it  is  found  that  boiler-makers,  who  appear  to  have 
their  catarrhal  deafness  increased  by  the  terrific  concussion  from 
riveting  boilers,  do  not  usually  complain  of  hyperaesthesia  or  of  pain- 
ful sensations  therefrom.  But  this  is,  perhaps,  a  question  of  sensi- 
tiveness to  such  impressions. 

Among  other  instances  known  to  the  writer,  the  following  are  of 
interest:  General  Leouidas  Polk,  a  few  days  after  the  battle  of  Bel- 
mont, was  standing  at  the  breech  of  an  eight-inch  rifled  gun,  which, 
on  being  fired,  burst  and  exploded  a  magazine  of  fixed  ammunition 
immediately  underneath  the  piece.  The  captain  of  the  battery  and 
four  or  five  others,  who  were  standing  near,  were  killed.  General 
Polk  was  very  miserable  for  a  few  moments  from  the  shock,  and  was 
confined  to  his  bed  for  some  ten  days.  The  left  ear  began  to  dis- 
charge the  day  of  the  injury,  and  continued  to  do  so  until  he  was 
killed,  two  and  a  half  years  later.  He  had  no  previous  aural  trouble, 
and  the  deafness  following  the  injury  was  the  cause  of  much  w^orry. 

General  Imboden,  in  an  article  in  TJie  Century  Magazine  for  May, 
1885,  states  that  at  the  battle  of  Manassas  he  squatted  under  the 
muzzle  of  a  smooth-bore  six-pounder  brass  cannon,  when  it  was  fired 
cfiE;  the  concussion,  he  says,  threw  him  twenty  feet  away,  causing 
momentary  unconsciousness.  There  was  a  gush  of  blood  from  the 
left  ear,  which  has  been  deaf  ever  since. 

Another  case  is  as  follows: 

David  McConnell,  late  a  private  ih  the  132d  N.  Y.  Volunteers, 
came  to  the  New  York  Ear  Dispensary  Nov.  14th,  1879,  at  which 
time  he  was  an  inmate  of  the  Soldiers'  Home  205  West  39th  street. 
He  stated  that  in  May,  1864,  whilst  leaning  against  a  strong  plank- 
ing outside  of  a  log  building,  in  which  some  torpedo  shells  were 
stored,  three  of  the  latter  exploded  simultaneously,  by  accident.  The 
shells  were  "about  the  size  of  a  pork  barrel."  Patient  was  thrown 
about  four  yards  by  the  force  of  the  explosion,  his  clothing  on  the 


WOUNDS   AND   INJURIES   OF   THE    DRUM-HEAD. 

left  side  being  torn  off  down  to  the  foot,  and  the  left  shoulder  much 
lacerated.  He  was  sent  to  a  hospital,  where  the  left  ear  began  to  dis- 
charge. He  suffered  for  months  with  distressing  tinnitus  aurium  and 
vertigo.  When  examined  by  the  author,  a  perforation  in  the  drum- 
head was  found,  and  chronic  purulent  inflammation  of  the  middle 
ear.  Hearing  was  considerably  diminished.  Patient  received  a  pen- 
sion of  two  dollars  a  month  in  1865,  "on  account  of  deafness  and 
prostration  of  nervous  system."  This  was  increased  to  $8  a  month 
in  1881,  to  $9  monthly  in  1884,  and  in  1885  to  $12  a  month.  In  a 
recent  letter  to  the  writer,  McConnell  says  that  the  discharge  from 
the  ear  has  ceased,  but  that  the  vertigo  remains.  He  cannot  hear 
the  loudest  ticking  watch  in  the  left  ear. 

The  following  case,  also  an  applicant  for  pension,  came  to  the 
New  York  Ear  Infirmary,  July  17th,  1877. 

This  patient,  Bernard  Cunningham,  stated  that  he  never  had  any 
aural  affection  until  after  the  battle  of  Gettysburg.  He  was  a  pri- 
vate in  Company  G,  8Uth  N.  Y.  V.,  and  states  that  on  July  1st 
(1863),  a  shell  exploded  near  his  left  ear,  from  the  stunning  effects 
of  which  he  did  not  recover  for  a  quarter  of  an  hour.  On  the  third, 
day,  a  thin  muco-purulent  discharge  was  noticed  coming  from  the 
left  ear;  it  soon  assumed  a  purulent  and  offensive  character.  Patient 
■said  that  an  aural  injury  was  diagnosed  by  Regimental  Surgeon 
Laugh  an  soon  after  the  injury  was  received. 

When  the  patient  was  seen,  fourteen  years  had  elapsed  since  the 
accident,  during  which  time  he  had  never  been  free  of  distressing 
tinnitus,  which  was  compared  to  the  constant  escape  of  steam  under 
high  pressure,  with  interruptions  synchronous  with  the  heart's  pulsa- 
tion. Autophonous  phenomena  were  experienced,  and  he  felt  that, 
unless  some  relief  was  obtained,  he  should  become  insane.  The  deaf- 
ness was  variable — at  times  very  great;  usually  he  could  hear  a  loud 
voice  only  in  the  left  ear. 

Examination  showed  the  external  auditory  canal  to  be  greater  in 
calibre  than  the  average,  and  the  drum-head,  which  was  correspond- 
ingly large,  had  a  circular  perforation  in  the  posterior-inferior  quad- 
rant about  three  millimetres  in  diameter. 

In  the  certificate  of  disability  given  this  soldier,  it  was  stated  that 
the  opening  in  the  drum-head  would  probably  never  close,  and  since 
there  would  be  a  tendency  to  frequent  exacerbations,  on  account  of 
the  exposure  to  which  an  out-door  laborer  is  subject,  the  discharge 
and  autophony,  thougli  temporarily  alleviated  by  treatment,  would 
probably  never  cease  altogether.' 

The  following  interesting  case,    taken    from   the   report   of  the 

'  The  Commissioner  of  Pensions,  the  Hon.  John  C.  Black,  informs  the 
writer,  in  a  letter  dated  February  7th,  1887,  that  Cunningham  is  now  a  pen- 
sioner "  at  the  rate  of  two  (2)  dollars  per  month  for  disease,  and  deafness  of 
the  ear." 

14 


ilO  WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 

Surgeon-General  of  the  Army  for  1886,  was  reported  by  Surgeon  C. 
H.  Alden,  U.  S.  A.,  Fort  Snelling,  Minn.: 

John  Kerston,  a  private  in  Light  Battery  F,  Fourth  Artillery,  24 
years  of  age,  a  Belgian  by  birth,  with  no  history  of  previous  aural  or 
throat  disease.  In  June.  1885,  while  salute  was  being  fired,  patient 
became  suddenly  deaf  in  the  left  ear.  The  hearing,  however,  returned 
in  a  few  hours,  patient  remaining  on  duty.  This  was  followed  in  a 
few  days  by  some  pain  in  the  ear  and  a  slight  discharge.  A  week 
afterwards,  when  the  patient  first  presented  himself  for  treatment, 
examination  of  the  left  ear  showed  a  somewhat  gaping  slit  in  the 
lower  anterior  quadrant  of  the  membrane,  extending  from  the  umbo 
to  the  circumference.  There  was  some  sero  purulent  discharge. 
Both  drum-heads  were  dull  and  uneven  in  appearance.  Eustachian 
tubes  impervious.  Hearing  in  right  ear  slightly  impaired;  in  the 
left,  ordinary  conversation  voice  at  four  feet  only.  Some  tinnitus. 
Left  membrane  healed  four  days  later.  Hearing  in  left  ear  then  for 
ordinary  conversation  six  feet.  Patient  experienced  no  further  trouble 
until  some  two  and  a  half  months  later,  when,  during  a  drill  of  his 
battery,  he  was  inadvertedly  placed  near  the  muzzle  of  one  of  the 
guns.  Immediately  after  the  discharge  of  the  piece,  })atient  fell  to 
the  ground  with  a  loud  cry  of  pain.  When  picked  up,  was  completely 
deaf  in  both  ears.  Severe  pain  in  head.  Both  drum-heads  were,  on 
examination,  found  ruptured  in  the  lower  anterior  quadrant.  Deaf- 
ness total  for  conversation  and  watch,  also  to  tuning  fork  held  against 
the  head.  The  rents  in  the  drum-heads  healed  in  the  course  of  a  few 
days,  and  the  pain  ceased.  The  hearing,  however,  did  not  return, 
and  patient  was  discharged  for  disability.' 

Injuries  like  the  above  are  especially  important  in  consequence  of 
affording  a  basis  for  claims  on  the  government  for  pensions. 

In  general,  it  may  be  said  that  the  concussion  of  great  guns  is  much 
less  in  the  rear  of  the  piece  than  just  over  or  at  one  side,  and  that  the 
more  in  advance  the  greater  the  exposure  to  the  blast.  On  shipboard 
a  gun's  crew  is  usually  stationed  from  four  to  eight  feet  to  the  rear 
of  the  muzzle,  and  when  protected  by  bulwarks  and  decks  experience 
no  special  inconvenience;  but  if  the  ear  happens  to  be  on  the  same 
plane  as  the  face  of  the  muzzle,  the  effect  at  a  distance  of  a  few  feet 
is  disagreeable,  or  even  painful,  and  causes  temporary  deafness  similar 
to  long-continued  concussion  previously  referred  to. 

The  force  of  impact  upon  the  drum-head  will  depend  somewhat  on 
the  size  and  curvature  of  the  external  auditory  canal  and  the  rigidity 
of  its  cartilaginous  walls;  of  course,  the  more  straight  and  large  the 
passage  the  greater  the  injury. 

'  Dr.  Alden,  in  a  letter  to  the  author,  says  that  Kerston  was  seen  about  six 
months  after  his  discharge  from  the  service;  that  his  hearing  had  improved 
slightly,  ordinary  conversation  voice  being  heard  at  about  the  distance  of  a 
foot. 


WOUNDS    AND   INJURIES   OF    THE   DRUM-HEAD.  21 1 

The  size  and  tensile  strength  of  the  drum-head  must  be  taken  into 
account ;  if  large,  and  brittle  from  trophic  changes,  it  is  much  more 
easily  ruptured. 

The  facing  of  the  person  exposed  must  also  be  considered — usually 
the  ear  directed  toward  the  object  from  which  the  concussive  force  is 
propagated  suffers  most — but  in  the  case  of  Ingram  it  was  otherwise, 
the  sound-waves  having  been  reflected. 

The  immediate  effect  of  the  blast-impact  in  the  cases  injured  by 
the  shell  explosion  at  Sandy  Hook  was  undoubtedly  upon  the  exterior 
surface  of  the  drum-head  mainly.  While  it  is  true  that  atmospheric 
tension  is  almost  equal  on  both  sides  of  the  drum-head,  yet  a  current 
of  air  passes  much  faster  along  the  comparatively  large  tube  compris- 
ing the  external  auditory  canal  than  along  up  the  small  Eustachian 
tube,  and  hence  in  most  of  these  cases  the  drum-head  was  driven  in 
and  contused  against  the  inner  wall  of  the  tympanum  and  retained 
air  with  great  force.  The  effect  of  such  violent  concussion  is  to  cause 
necrosis  of  the  membrane. 

The  momentum  of  sound-waves  may  ordinarily  be  estimated  by  tho 
application  of  the  law  of  central  forces — the  force  being  inversely  to 
the  square  of  the  distance;  the  effects,  practically,  of  such  intense 
concussive  force,  however,  cannot  be  measured  by  rules  governing^ 
sound  ordinarily,  since  it  has  been  found  by  experience  that,  instead 
of  finding  himself  surrounded  near  the  breech  of  the  gun  by  highly 
rarefied  air,  the  experimenter  may  be  subjected  to  quite  an  opposite 
condition,  namely,  one  of  condensation.  In  the  former,  intra-tym- 
tympanic  air  would  rush  outwardly,  pushing  the  drum-head  before  it. 
In  confirmation  of  this  allegation  the  puzzling  experience  related  to 
the  writer  by  Captain  Shaler,  U.  S.  A.,  may  be  cited  :  The  window- 
panes  of  the  officers'  quarters  at  the  testing-grounds  at  Sandy  Hook, 
situated  some  three  to  five  hundred  feet  to  the  westward  of  the  gun- 
park,  are  liable  to  be  shattered  by  the  concussion  of  large  pieces  in 
practice,  and  it  has  been  found  that  the  glass  is  forced  outward  at  one 
time  and  inward  at  another.  Eegarding  the  drum-heads  as  window- 
glass  under  like  conditions,  we  might  find  them  ruptured  by  compres- 
sion from  without  in  one  instance,  and  by  distention  of  intra-tympanic 
air  in  another. 

All  of  us  are  aware  of  the  difficulty  of  ascertaining  the  source  of 
sound  in  a  sea-fog,  where  aqueous  vapor-tension  varies  in  a  much 
greater  degree  than  inland.  Professor  Henry  described  the  reflections 
of  sound  which  here  take  place  as  "  acoustic  shadows,"  a  picturesque 
comparison  recognizable  by  every  one  familiar  with  those  similar 
phenomena,  namely,  the  reverberatory  detonations  of  thunder  during 


212  WOUNDS    AND    INJURIES    OF    THE    PfiUM-HEAD. 

a  storm,  where  clouds  or  mountain  peaks  intervene.  It  is  to  the  un- 
recognizable aqueous  vapor  "  peaks  "  and,  even  on  clear  days,  the 
variously  heated  strata  of  which  the  air  may  be  composed,  that  many 
unexplained  and  puzzling  acoustic  manifestations  are  due.  In  the 
case  of  Corporal  Ingram,  cited,  the  wave  from  the  blast  did  not  nearly 
so  much  affect  the  right  ear,  which  was  turned  toward  the  shell,  as 
the  left  one,  the  sound  having  been  apparently  deflected  from  its 
course  by  the  heavy  gun-carriage  intervening.  General  Franklin,  in 
describing  the  battle  of  Gaines\s  Mill,  in  Tlie  Century  Magazine,  July, 
1885,  says  it  was  not  heard  a  mile  and  a  half  away;  he  thinks  the 
dense  woods  intervening  prevented  the  passage  of  sound.  The 
*' silent  battle,'^  as  the  action  at  Gaines's  Mill  has  been  designated  by 
General  E.  M.  Law,  of  Lee's  army,  also  attracted  the  attention  of  the 
Confederates;  some  officers  who  were  near  witnesses  not  hearing  a 
sound  of  the  battle,  though  the  direction  of  the  lines  of  battle  were 
distinguishable. 

The  author  distinctly  saw  the  troops  in  action  on  one  portion  of  the 
field  during  the  battle  of  South  Mountain;  large  volumes  of  smoke 
were  seen  to  ascend  after  each  discharge  of  the  cannon,  and  lesser  ones 
from  the  musketry,  and  yet  the  roar  and  crash  therefrom  were  mostly 
unheard.  On  the  other  hand,  the  writer  recollects  hearing  the  can- 
nonading at  the  first  battle  of  Bull  Eun  distinctly,  though  he  was  with 
troops  more  than  one  hundred  miles  distant.  Although  the  deaden- 
ing effects  of  varying  aqueous  vapor-tension  exercises  a  notable  in- 
:fluence  on  the  behavior  of  sound,  the  force  of  the  wind  has  much  to 
do  with  the  extent  of  its  travels. 

Experiments  are  wanting  to  determine  the  windage'  of  balls.  This 
must  depend  on  t^eir  size  and  velocity,  nearness  of  passage,  and  the 
force  and  direction  of  the  wind.  There  seems  to  be  no  doubt  but 
that  the  windage  of  a  cannon-ball  might  rupture  the  drum-head  of 
the  ear.  The  compression  of  the  air  before  and  around  the  ball,  the 
author  has  been  informed  by  Professor  A.  M.  Mayer,  is  considerable, 
and  the  velocity  of  the  compression  is  equal  to  that  of  the  ball,  which 
velocity  may  even  exceed  that  of  wind  itself.  So,  an  aerial  Mow  of 
auch  a  mass  of  air,  at  such  high  velocity,  is  probably  quite  sufficient 
to  rupture  the  drum-head. 

The  size  and  force  of  modern  military  explosives  having  been  greatly 

^  "  Windage,"  it  should  be  said,  is  a  technical  term  used  in  military  par- 
lance to  indicate  the  difference  in  diameter  between  the  bore  of  a  gun  and  its 
projectile.  The  word  has  been,  perhaps  improperly,  adopted  by  writers  on 
military  surgery,  in  which  sense  it  refers  to  the  impact  of  the  condensed  air 
fiurrounding  a  missile  passing  near  any  part  of  the  body. 


WOUNDS    AND    INJURIES   OF   THE   DRUM-HEAD.  213 

increased  of  late  years,  much  more  injury  to  the  ear  is  likely  to  occur 
in  future  than  has  been  recorded  of  the  past,  though  the  number  of 
accidents  from  premature  discharge  or  from  exposure  to  the  blast  in 
firing  breech-loading  pieces  must  be  less  than  when  muzzle-loaders 
were  in  vogue. 

The  extent  of  the  injury  of  the  drum  of  the  ear  in  each  one  of  the 
cases  reported  was  dependent  on  the  distance  from  the  shell,  the  fac- 
ings at  the  moment  of  explosion,  and  the  size  of  the  external  audi- 
tory canal.  In  some  instances,  as,  for  example,  in  the  cases  of  Ab- 
bott, Clark,  Goodno,  Ingram,  and  Sinclair,  the  drum-heads  were 
driven  in  with  such  force  as  to  cause  their  complete  destruction  by 
death  of  the  tissues.  In  some  of  the  cases,  it  will  be  observed  that 
partial  or  entire  reproduction  of  the  drum-head  took  place.  The 
spontaneous  cure,  in  most  these  cases,  without  leaving  any  discharge, 
affords  a  valuable  suggestion  in  the  treatment  of  inflammation  of  the 
ear,  as  well  as  in  operations  on  the  organ,  in  healthy  persons.  It  is 
believed,  notwithstanding  the  great  destruction  of  the  membrana 
tympani,  that  the  chain  of  ossicles  has  been  left  in  every  case.  It  is 
fortunate  for  man  that  great  augmentation  of  tension,  exerted  either 
from  without  or  from  within,  upon  the  transmitting  mechanism  of 
the  ear,  may  be  experienced  without  serious  injury  to  the  stapes  or 
labyrinth. 

It  is  the  experience  of  many  officers  that  the  vibrations  of  great  in- 
tensity which  are  given  off  from  some  field-pieces  and  bursting  shells, 
charged  with  high  explosives,  are  more  disagreeable  than  the  heavier 
sounds  of  great  guns.  The  metal  itself  vibrates  under  these  circum- 
stances similarly  to  a  tuning-fork. 

A  very  disagreeable  jar  is  imparted  to  the  temporo-maxillary  artic- 
culation  when  the  individual  is  near  a  great  gun  being  fired  off.  This 
is  lessened,  it  is  believed,  by  standing  on  the  toes  and  leaning  forward. 
Some  simple  precaution,  to  be  employed  by  officers  and  men  during 
artillery  practice,  would  seem  very  much  needed,  since  aural  shock  is 
not  only  painful  and  distressing,  but  orders  cannot  be  well  heard 
while  the  confusion  lasts.  It  would,  furthermore,  seem  advisable  that 
artillerists  should  stand  facing  the  piece  whilst  it  is  being  fired,  as  the 
force  of  the  concession  would  then  be  very  materially  lessened,  as  far 
as  the  ear  is  concerned.  The  case  of  Dr.  Mayo,  above  given,  is  of  in- 
terest in  this  respect,  as  showing  the  disagreeable  effects  of  sudden 
impact  of  sound  from  an  unexpected  source  coming  directly  upon  the 
ear. 

There  is  probably  no  better  protection  than  a  firm  wad  of  cotton- 
wool well  advanced  into  the  external  auditory  canal.     In  suggesting 


•2^14  WODNDS    AND    INJUKIES    OF    THE    DRUM-HEAD. 

this  protection,  it  is  believed  that  harm  can  seldom  take  place  from 
pressure  of  air  from  within,  since  it  is  known  that  the  violent  introduc- 
tion of  air  into  the  tympanum  from  the  throat,  by  means  of  Politzer's 
method  of  inflation,  seldom  ruptures  the  drum-head,  though,  if  such 
a  volume  of  air  were  suddenly  driven  into  the  external  auditory  canal, 
and  the  drum-head  would  often  be  ruptured. 

B.    THE    CONCUSSION    OF   THE   ULAST   OF   SMALL   ARMS    AND 
EXPLOSIVES. 

The  ear  is  not  liable  to  injury  from  the  so-called  windage  of  mis- 
siles of  small  arms;  but  when  in  the  blast  of  light  explosives,  rupture 
and  other  injuries  of  the  drum-head  may  take  place. 

The  following  are  examples: 

Case  1. — Male,  21  years  of  age.  One  year  and  a  half  ago  a  horse 
pistol  was  fired  off  close  to  his  right  ear.  For  a  few  days  he  experi- 
enced noise  and  pain  in  the  ear,  but  deafness  was  not  observed  until 
six  months  afterwards.  The  right  drum-head  is  densely  opaque,  but 
there  is  no  cicatrix.  The  deafness  seems  due  as  much  to  chronic 
head  catarrh  as  to  the  concussion.     Canals  large. 

Case  2. — Male,  24  years  of  age.  Six  weeks  ago.  on  July  4th,  a 
pistol  was  fired  off  close  to  his  right  ear,  which  was  previously  unaf- 
fected. There  were  no  symptoms  at  the  time,  but,  on  awaking  the 
next  morning,  he  found  the  ear  was  discharging.  It  has  run  ever 
since.  Tinnitus  existed  for  six  months,  "  like  the  striking  together 
of  pieces  of  metal  or  glass;  "  it  was  intermittent.  Some  inspissated 
pus  was  removed  from  the  right  ear;  the  drum-head  was  dull-looking, 
and  in  the  inferior  segment  a  perforation  was  filled  with  granulation 
tissue.     The  canals  were  laige. 

Case  3. — Male,  32  years  old.  At  age  of  eighteen  years,  a  pistol  was 
fired  off  near  his  right  ear.  There  was  much  tinnitus,  and,  later  on, 
a  discharge,  which  has  existed  ever  since.  Hears  now  loud  voice  only 
in  right  ear.  The  perforation  is  concealed  by  secretions.  Canals  are 
large.     Patient  seen  only  once. 

Case  4. — Patient,  male,  aged  7  years,  comes  with  the  statement 
that  yesterday,  July  4th,  a  boy  exploded  a  fire-cracker  "into  the  left 
ear."  There  has  been  much  pain  ever  since,  but  no  deafness.  The 
left  drum-head  is  inflamed  looking;  the  inner  end  of  the  canal  is 
desquamating.     Only  seen  once. 

Case  5. — Female  patient,  aged  64  years.  On  July  4th,  a  month 
ago,  a  young  man  fired  off  a  pistol  twice  within  two  or  three  feet  of 
her  left  ear,  causing  immediate  deafness  and  autophonia,  which  still 
exist.  No  pain  was  experienced.  The  drum-head  is  opaque,  but  no 
evidence  of  any  rupture  remains. 


WOUNDS    AND   INJURIES    OF   THE    DRUM-HEAD.  215 

C.    FROM    LONG-CONTINUED  MUSKETRY  FIRE,  RAPID-FIRING   MACHINE 

GUNS,    ETC. 

It  has  always  ssemed  to  the  writer  that  exposure  of  the  drum-head 
to  the  loag-continued  shock  of  musketry  fire  was  injurious,  though 
no  case  of  deafness  was  traced  to  this  cause  while  in  the  field.  The  fol- 
lowing case,  referred  to  him  by  Medical  Director  Delevan  Bloodgood, 
TJ.  S.  N.,  however,  seems  to  confirm  the  above  conjecture.  For  its 
history  the  author  is  indebted  to  Passed  Assistant  Surgeon  Frank 
Anderson,  U.  S.  Steamship  Kichmond. 

David  C ,  ordinary  seaman,  23  years  of  age,  on  October  27th, 

1887,  was  engaged  in  firing  at  a  target  with  a  Gatling  gun  in  the 
bow  of  a  ship's  cutter.  He  stood  about  two  feet  from  the  muzzle  of 
the  gun,  passing  ammunition,  and  to  leeward  of  it,  his  back  toward 
the  bow,  the  left  ear  at  first  turned  to  the  piece,  but  when  standing 
erect,  some  foot  and  a  half  above  it,  during  the  firing  of  a  thousand 
rounds  of  cartridges.  The  firing  occupied  about  fifteen  minutes. 
The  discharges  were  in  volleys  of  two  hundred  each,  there  being 
about  two  minutes'  interval  between  each  volley.  Patient  became  so 
deaf  after  about  four  hundred  rounds  had  been  fired,  that  he  could  no 
longer  hear  the  orders  given  by  the  man  feeding  the  gun.  He  there- 
fore turned  about  while  passing  the  rest  of  the  ammunition,  so  as  to 
bring  the  right  ear,  which  seemed  less  aflFected,  toward  the  piece, 
turning  half  round  when  reaching  for  cartridges.  There  was  a 
^'  stinging  pain  "  in  and  about  the  ears,  extending  through  the  head, 
especially  the  forehead,  and  when  the  last  shot  was  fired  he  ''could 
not  hear  anything."  On  returning  aboard  ship,  about  fifteen  minutes 
afterward,  he  found  that  the  deafness  was,  if  possible,  increasing, 
and  in  about  a  quarter  of  an  hour  it  was  total.  The  head  pained  for 
some  two  weeks,  and  there  was  vertigo;  the  pain  behind  the  ears  and 
sensitiveness  to  touch,  especially  on  the  left  side,  still  continues. 

The  left  mastoid  was  blistered  while  on  ship,  where  he  remained 
three  weeks  after  the  injury.  At  first  he  was  very  nervous  and  could 
not  sleep  well  on  account  of  the  noise  and  distress  in  ears  and  head, 
though  he  felt  very  drowsy.  He  is  now  in  the  Naval  Hospital,  where 
the  left  mastoid  has  been  blistered  three  times  and  rubbed  with  oleate 
of  mercury,  and  he  is  under  a  moderate  course  of  iodide  of  potassium. 
The  patient  is  of  full  medium  size  and  has  been  in  good  health,  though 
he  never  considered  himself  very  strong.  There  is  no  history  of  any 
constitutional  disease,  and  he  says  his  hearing  has  always  been  very 
good.  When  examined  by  the  writer  (January  18th,  1888),  he  did 
stagger,  but  occasionally  felt  a  sensation,  lasting  a  few  minutes,  as  if 
something  was  turning  around  in  his  head.  He  has  lately  complained 
of  slight  '•  weakness"  of  the  left  eye,  probably  due  to  slight  paresis  of 
the  facialis.     He  is  much  run  down  and  mentally  depressed. 

Examination  of  ears. — Left  ear:  The  drum-head  shows  trophic 
changes;  at  the  umbo  and  posterior  segment,  radiating  fibres  are  ex- 
posed to  view.      Short   process  very  prominent.     Stapes  and  long 


216  WOUNDS   AND   INJURIES   OF   THE   DRUM-HEAD. 

process  of  incus  are  plainly  visible  through  the  drum-head.  There 
has  been  very  decided  chronic  catarrhal  otitis  media.  The  entire 
peri-auricular  region  is  tender  to  touch,  though  no  other  part  of  the 
hcad'is.  Right  ear:  Some  symptoms  of  recent  chronic  catarrh  are 
present.  The  drum-head  is  less  trophic  than  the  left.  The  cone  of 
light  is  high  up,  above  the  umbo.  Malleus  plexus  and  tissues  about 
the  anterior- superior  quadrant  are  very  decidedly  injected. 

Hearing. — At  the  sham  battle  which  took  place  at  Newport,  after 
his  injury,  he  was  on  deck  of  the  Eichmond  and  saw  the  action,  but 
could  hear  no  sound,  not  even  the  guns  of  his  own  ship,  though  he 
felt  the  deck  tremble.  The  deafness  is  absolute;  cannot  hear  any  im- 
pression of  sound.  Large  vibrating  tuning-fork  on  teeth  or  any  part 
of  skull  not  heard.  Does  not  hear  shouting  or  screaming  into  tlie  ear 
through  a  conical  conversation-tube.  Patient  does  not  hear  his  own 
voice,  but  speaks  with  very  good  modulation. 

The  importance  of  facing  the  piece  in  firing  is  shown  by  the  result 
of  neglecting  such  a  precaution  in  this  case,  where  the  ear  was  pre- 
sented to  the  muzzle — the  effect  of  impact  being  greater  owing  to 
the  direction  of  the  wind.  Nor  were  the  ears  protected  by  cotton- 
wool in  the  external  auditory  canals,  which  were  large.  It  may  be 
remarked  that  the  regularity  and  frequency  of  the  impacts  of  in- 
tense sound  upon  the  drum-head  were  sufficient  in  this  case  to  pro- 
duce neuritis  of  the  auditory  nerve,  though  the  drum-head  was  not 
ruptured.  The  intense  vibrations  of  the  barrels  of  the  Gatling  gun, 
when  rapidly  fired,  are  very  distressing  to  hear,  even  at  some  dis- 
tance to  the  rear.  They  seem  to  vibrate  much  in  the  same  manner  as 
a  tuning-fork. 

Colonel  Alfred  Mordecai,  of  the  Ordnance  Department,  U.  S.  A., 
informs  the  writer  that  the  effect  on  the  ear  of  volleys  from  rapid- 
firing  machine  guns  are,  even  at  some  distance,  exceedingly  disagree- 
able, especially  when  fired  with  the  rapidity  of  1,200  rounds  per 
minute.  These  guns,  for  practice,  are  seldom  fired  more  rapidly  than 
100  rounds  per  minute,  though  in  the  above  recorded  case  the  rate 
was  at  about  200  per  minute. 

D.    FROM    THE   IMPACT   OF  INTENSE  SOUNDS   PROCEEDING  FROM  STEAM 
WHISTLES,    LOUD   VOICE,    AND   METAL    HAMMERING. 

All  very  loud  sounds  are  generally  regarded  as  disagreeable,  and  if 
long  borne  may  not  only  irritate  the  transmitting  mechanism  of  the 
drum  which  is  thus  kept  unduly  active,  but  the  perceptive  apparatus 
and  central  auditory  tract  may  suffer  from  irritation  also.  The  fol- 
lowing eases  are  examples  : — 


WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD.  217 

Screaming  in  the  ear. 

Male,  20  years  of  age.  Eight  months  ago,  while  out  boating, 
his  companion,  a  woman,  oame  close  to  his  right  ear  with  her 
mouth  and  screamed:  "  What  did  you  say?"  in  the  highest  pitch  of 
her  voice.  This  caused  immediate  pain  and  tinnitus  like  loudly-ring- 
ing bells.  He  was  perspiring  freely  at  the  time,  and  feeling  tired  lay 
down  in  the  boat  and  slept  for  two  hours  in  the  night  air.  For  two 
days  afterwards  he  was  "hoarse,"  and  thinks  he  had  a  "cold." 
Three  weeks  later  he  experienced  deafness  in  the  right  ear  and 
"numbness";  these  symptoms  have  recurred  once  or  twice. 

Examination  showed  that  the  distress  was  due  to  a  collection  of 
cerumen,  which  having  become  loosened  whilst  he  was  perspiring, 
was  impacted  by  the  sound  of  the  woman's  voice,  and  thus  caused  a 
slight  inflammation  of  the  drum-head. 

Rupture  of  drum-head  from  a  locomotive  ivMstle. 

Daniel  McLaren,  Esq.,  consulted  the  writer  in  1873.  He  was 
then  54  years  of  age.  He  stated  that  twenty-four  years  ago,  whilst 
an  engineman  on  the  Boston  and  Worcester  Railroad,  he  blew  the 
whistle  of  his  engine  while  passing  under  a  roadway.  He  was  stand- 
ing with  the  left  ear  toward  the  open  window  of  the  cab,  thereby 
exposing  it  to  the  intense  sound.  The  drum  head  was  ruptured,  as 
shown  by  the  cicatrix  remaining,  and  hearing  has  been  defective  ever 
since.  Mr.  McLaren,  subsequently  President  of  the  Cincinnati, 
Hamilton  and  Dayton  Railroad  Company,  having  become  somewhat 
deaf  in  the  right  ear  from  otitis  media  chronica,  suffered  much  greater 
inconvenience  from  the  defect  in  the  left  ear  than  ever  before. 

Injuries  of  the  ear  from  the  intense  sound  produced  by  steam 
whistles  are  not  uncommon.  The  Superintendent  of  the  Amboy 
Division  of  the  Pennsylvania  Railroad  Company,  informs  the  writer, 
in  a  letter  dated  January  23d,  1888,  that  an  engineman  was  over- 
come recently  by  the  prolonged  ami  intense  sound  of  a  locomotive 
steam  whistle;  he  blew  his  whistle  for  a  road  crossing  and  the  valve, 
getting  out  of  order,  refused  to  close.  The  whistle  continued  blowing 
until  the  train  stopped  at  the  station.  The  man  was  so  near  the  source 
of  the  sound  that  he  became  vertiginous,  and  it  was  necessary  to  lift 
him  from  his  engine  and  assign  another  man  to  his  place.  Others 
around  the  train  were  affected  disagreeably,  but  none  so  severely.  The 
man  recovered  from  the  shock  to  his  nerves  in  a  short  time. 

Metal  hammering. — Operatives  exposed  to  the  intense  noise  of 
metal  hammering  experience  more  or  less  injury  of  the  ears  according 
to  the  violence  of  the  vibrations  and  the  condition  of  their  ears. 
Deafness  in  these  cases  is  much  more  likely  to  arise  from  the  impact 


218  WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 

of  sound  where  sclerosis  resulting  from  inflammation  of  the  mucous 
membrane  of  the  middle  ear  already  exists. 

The  healthy  ear  is,  however,  less  liable  to  injury  in  this  way. 
Boiler-makers  are  nearly  all  of  them  a  little  deaf,  but  as  with  artille- 
rists and  caisson-workers,  it  is  not  easy  to  estimate  the  amount  of  im- 
pairment due  to  either  cause  respectively.  Most  boiler-makers  seem 
to  hear  best  in  a  noise,  and  they  always  converse  while  at  work.  The 
writer  has  been  informed  by  employers  that  some  men,  even  after 
working  at  boiler-making  for  forty  years,  do  not  experience  any  deaf- 
ness. 

The  following  cases  are  illustrative  : 

Case  1. — Patient,  a  tinsmith,  33  years  of  age,  stated  that  a  year 
previously  he  was  employed  during  one  day  in  riveting  a  large  cast- 
iron  water  tank.  His  work  consisted  in  holding  a  hammer  against 
the  inside  of  the  tank  while  another  mechanic  hammered  upon  the 
rivets  on  the  outside.  His  right  ear  was  exposed  to  the  terrific  din 
during  the  entire  day,  not  being  more  than  one  foot  away  from  the 
source  of  sound.  The  following  day  the  patient  found  that  the  right 
ear  was  very  deaf,  and  since  then  the  deafness  has  remained  about  the 
same. 

Examination  showed  evidences  of  long-standing  chronic  middle-ear 
catarrh  on  both  sides. 

Case  2. — Patient,  34  years  of  age,  has  been  a  metal  hammerer  for 
eighteen  years.  From  the  beginning  had  tinnitus  in  left  ear,  and  this 
he  believes  has  been  greatly  increased  by  noisy  work  on  metals,  as 
riveting  and  the  like.  When  he  stopped  working  there  was  so  much 
"  whistling "  in  the  ear  that  he  finally  became  afraid  to  work  any 
longer.  On  examining  the  left  ear,  the  canal  was  found  filled  with 
pus,  debris  of  inspissated  wax  and  epithelium,  the  drum-head  being 
absent.  The  malleus  remained,  held  by  mere  shreds  of  membrane. 
In  the  right  ear  there  had  never  been  any  tinnitus. 

Case  3. — Patient,  38  years  old,  began  working  at  boiler-making  four- 
teen years  ago.  The  first  week  he  was  so  much  affected  that  he  could 
not  hear  conversation.  He  soon  got  used  to  the  noise  and  continued  this 
occupation  for  five  years.  The  canals  are  large.  A  large  mass  of  wax 
was  removed  from  the  right  ear,  showing  the  presence  of  two  chalky 
deposits  just  behind  the  malleus  handle. 

Case  4. — Patient,  50  years  of  age,  had  a  discharge  from  the  left  ear 
which  began  at  the  age  of  eight  years,  and  lasted  for  twenty  years. 
When  thirty  years  of  age  he  began  boiler-making,  following  this  oc- 
cupation for  six  years.  During  this  period  his  hearing  became  very 
bad  ;  he  could  only  hear  loudest  shouting  for  an  hour  after  quitting 
work.  He  always  wore  lamb's  wool  in  ears  while  at  work.  After  he 
gave  up  this  occupation,  his  hearing  improved. 

Case  5.— For  three  years,  this  patient,  21  years  of  age,  has  had 


WOUNDS    AND    INJURIES    OF    THK    DRUM-HEAD,  219 

variable  deafness  and  autophonia  ;  also  tinnitus  in  both  ears.  For 
one  year  past  has  worked  at  sheet-iron  riveting,  which  has  very  much 
increased  the  tinnitus.  His  teeth  are  very  carious  and  there  is  free 
ceruminal  secretion. 

Case  6. — Patient,  61  years  old.  At  the  age  of  twenty-three  he  had 
typhoid  fever,  being  afterwards  very  deaf  for  nine  months.  For 
twenty-four  years,  from  his  twenty-sixth  to  his  fiftieth  year,  he  worked 
in  a  boiler  yard,  which  increased  his  deafness  very  much.  Nine  years 
before  quitting  this  work  he  had  autophonia  in  both  ears,  but  has 
never  had  any  pain.  The  canals  are  large,  and  from  the  left  a  large 
plug  of  inspissated  cerumen  was  removed. 

Case  7. — Patient.  67  years  of  age.  has  worked  in  a  boiler  shop  for 
twenty-eight  years.  At  first  the  noise  in  the  head  on  coming  out  of 
the  shop  was  very  great,  and  still  continues  when  he  stops  work. 
Patient  gets  overheated  at  his  work  and  takes  cold  easily  and  very  fre- 
quently. Has  been  deaf  for  eight  ye.irs,  and  the  tinnitus  has  been 
worse  for  three  years  past.  From  the  right  ear  a  large  mass  of  desic- 
cated cerumen  was  removed,  a  small  amount  from  the  left. 

Case  8. — Mechanic,  aged  38  years,  had  first  noticed  deafness  while 
apprenticed  at  boiler-making,  in  his  seventeenth  to  twentieth  years. 
After  hard  blows  in  the  boiler  the  sound,  he  said,  seemed  to  pass 
through  his  ears,  leaving  a  "  sick  feeling,"  as  though  they  were 
swollen.  This  would  happen  several  times  a  day.  He  heard  no  bet- 
ter in  a  noise.  He  always  had  been  troubled  with  nasal  catarrh,  and 
the  drum-heads  showed  evidences  of  the  existence  of  chronic  catarrh 
of  the  middle-ear. 

Boiler-makers  find  that  the  wearing  of  cotton-wool  in  the  ears  is  a 
source  of  much  protection  against  the  damaging  effects  of  the  con- 
tinual impact  of  sound  on  their  ears. 


5.    CONTUSED    AND    PENETRATING    WOUNDS    OF    THE 

DRUM-HEAD   FROM   OBJECTS    THRUST    INTO 

THE   EAR. 

Incised  wounds  of  the  drum-head  are  not  uncommon.  They  are 
usually  caused  by  the  sudden  and  accidental  thrust  of  sharp  objects 
introduced  into  the  external  auditory  canal  for  the  purpose  of  scratch- 
ing the  ear  or  in  play  ;  hair-pins,  small  pencils  and  the  like,  usually 
in  the  hands  of  women  and  children,  often  do  much  harm  in  this 
way. 

The  drum-head  is,  furthermore,  often  wounded  by  the  sharp  in- 
struments employed  by  unskilful  persons  in  attempts  at  the  removal 
•of  foreign  bodies  from  the  ear. 


220  WOUNDS    AND    INJURIES    OF    THE    DRUM-HEAD. 

The  following  are  cases  in  point: 

Case  1. — Male,  33  years  of  age,  first  seen,  August  23d,  1878.  While- 
out  fishing  with  a  friend  six  days  ago,  the  latter  was  standiug  a  short 
distance  away,  holding  the  handle  of  his  rod  against  his  body  with 
the.  tip  pointing  towards  the  patient's  head.  Patient,  in  turning  his 
head,  suddenly  and  violently  forced  the  sharp  tip  of  his  companion's 
rod  into  the  left  ear,  with  a  sensation  resembling  the  "snapping  of  a 
piano-string."  He  suffered  instantaneous  pain  and  fell  over  on  the 
ground  with  a  feeling  of  "  spinning  around  like  a  top."  The  rod 
was  now  pulled  out  of  the  ear  and  he  was  able  to  rise  with  assistance, 
though  he  could  not  stand  or  walk  uuaided.  Pain  was  only  noticeable 
at  the  moment  of  injury.  He  was  not  unconscious  at  the  time,  but 
when  struck  was  dazed  and  fancied  for  the  moment  that  he  was  falling 
into  the  water.  He  was  taken  home  "  as  a  drunken  man  would  be" 
and  vomited  several  times.  Patient  was  kept  under  observation  for 
two  months,  during  which  time  the  vertiginous  symptoms  were  very 
marked.  The  perforation  was  in  the  posterior  superior  quadrant  of 
the  drum-head. 

Patient  was  not  seen  again  until  January  18th,  1888.  During  the 
two  or  three  years  following  the  above-named  injury,  he  had  two  at- 
tacks of  vertigo  in  the  street.  His  general  health,  however,  is  now 
good.  There  is  a  small  manometric  cicatrix  in  the  left  drum-heati  at 
the  site  of  the  old  perforation.  Hearing  in  this  ear  for  plain  ordinary 
voice  at  five  feet  only.     There  is  also  constant  *'  buzzing." 

Case  2. — Male,  7  years  of  age.  Seven  days  ago,  he  put  the  blunt 
end  of  a  hair-pin  of  medium  size  into  the  right  ear,  when  his  brother 
ran  against  it  and  forced  it  deeply  into  the  ear,  causing  pain  and 
bleeding.  The  pain  is  now  severe  and  the  discharge  purulent.  Hears 
loud  voice  only.  The  drum-head  is  perforated  in  the  anterior-superior 
quadrant.  When  last  seen,  a  week  later  on,  the  perforation  was 
healing. 

Case  3. — Female,  aged  50.  Three  weeks  ago  had  a  head  cold  with 
pains  in  both  ears.  Four  days  ago  she  experienced  a  tickling  sensa- 
tion in  the  right  ear  and  introduced  a  hairpin;  there  is  a  perforation 
in  the  right  drum-head.     Seen  but  once. 

Case  4. — Male,  26  years  old.  Four  days  ago,  while  lying  on  a 
lounge,  his  two-year-old  child  inserted  one  end  of  a  slender  paper- 
cutter  into  the  right  ear.  The  father  being  semi-conscious  at  the 
time,  jumped  up  and  brushed  the  paper-cutter  aside  with  his  hand, 
breaking  it  into  three  pieces,  one  of  which,  over  an  inch  in  length, 
remained  wedged  in  the  canal.  Some  difficulty  attended  its  removal:, 
it  was  covered  with  blood.  A  discharge  was  not  noticed  until  the 
third  day,  but  exists  now.  There  has  been  considerable  tinnitus. 
There  is  pain  and  a  perforation  whistle.  He  remained  under  obser- 
vation for  two  months  before  the  drum-head  healed.  Canals  were 
very  large. 

Case  5. — Male,  aged  20.     Two  days  ago  a  younger  brother  waked 


WOUNDS    AND    INJURIES   OF  THE   DRUM-HEAD.  221 

him  up  in  the  morning  by  inserting  a  broom-straw  into  the  right  ear. 
The  drum-head  was  thereby  contused,  but  no  pain  was  felt.  In  half 
an  hour,  however,  there  was  tinnitus  and,  at  night,  headache,  espe- 
cially on  the  right  side,  and  sleeplessness.  Hears  loud  voice  only  in 
the  injured  ear.  The  posterior  superior  quadrant  of  the  drum-head 
was  the  seat  of  a  large  exudation  blood  cyst.  When  this  finally  dis- 
appeared, the  membrane  was  found  perforated.  The  wound  of  the 
straw  seems  to  have  severed  a  branch  of  the  mallear  plexus.  Patient 
was  only  seen  three  times. 

Case  6. — Male,  28  years  of  age.  Three  years  ago,  while  having  a 
carrier  armed  with  cotton- wool  passed  into  the  left  ear  for  the  instruc- 
tion of  students,  the  doctor  passed  it  in  too  far,  rupturing  the  drum- 
head, and  causing  sudden  pain,  followed  in  a  few  days  by  a  discharge. 
An  opacity  now  marks  the  seat  of  the  injury. 

Case  7. — Female,  aged  27.  Yesterday  evening  her  child  struck  a 
slate-pencil  with  which  the  patient  was  scratching  her  left  ear. 
Blood  flowed  at  the  time,  and  the  pain  in  the  ear  was  intense.  Head- 
ache, tinnitus,  vertigo,  and  autophonia.  The  drum-head  perforated. 
When  last  seen,  thirteen  days  after  the  injury,  patient  was  improving. 

Case  8. — Female,  aged  24.  Three  days  ago,  in  attempting  to 
remove  a  foreign  body  from  the  left  ear,  a  druggist  perforated  the 
drum-head  with  a  crochet  needle.  The  patient  fainted.  Ear  was 
afterwards  syringed.  Has  pain  and  tinnitus.  Hears  loud  voice  only 
at  ten  feet.     Membrane  healed  slowly. 

Case  9. — Female,  27  years  of  age.  Eight  years  ago  wounded  the 
<3rum-head  of  right  ear  while  picking  the  ear  with  a  hairpin.  The 
ear  bled,  was  painful,  and  she  had  deafness  and  tinnitus.  There  is 
now  a  purulent  discharge,  which  has  probably  existed  ever  since  the 
injury. 

Case  10. — Male,  33  years  of  age.  Two  weeks  ago  a  tightly  rolled 
paper  lighter  was  violently  thrust  into  the  right  ear  in  play.  Pain 
and  tinnitus  were  immediate  and  severe  for  twenty-four  hours — since 
then  dull.     Perforation  whistle  on  blowing  nose.     Healing  was  rapid. 


6.    mJUEY   TO    THE  DKUM-HEAD   FROM  VIOLENT    SY- 
RINGING OF  THE  EAR  AND   IN  SURF  BATHING. 

A  stream  of  water  in  violent  syringing,  especially  for  the  removal 
of  cerumen,  is  liable  to  rupture  the  drum-head  when  care  is  not  exer- 
cised. The  author  has  seen  a  number  of  such  cases.  One  example, 
however,  will  be  sufficient. 

Male  patient,  29  years  of  age.  When  ten  years  old,  while  suffering 
from  eczema  of  the  auricles,  the  ear  was  violently  syringed  out  by  a 
physician  with  a  large  syringe  used  to  administer  enemas.  The  force 
of  impact  upon  the  drum-head  was  such  as  to  knock  the  patient  down. 


222  WOUNDS    AND    INJURIES   OF    THE    DRUM-HEAD. 

The  rupture  in  the  membrane  never  healed;  in  fact,  the  membrane  is 
now  almost  missing,  and  there  exists  a  purulent  discharge. 

The  reader  should  consult  Chapter  VIII.  for  an  account  of  the 
injuries  to  the  ear  from  bathing. 

7.  LESIONS   OF  THE   DRUM-HEAD   FROM  VIOLENT 
TRACTION   ON  THE  AURICLE. 

The  act  of  frowning  in  certain  persons  is  attended  by  such  contrac- 
tion of  the  anterior  auricular  muscle  and  the  fascia  going  to  the 
drum-head,  that  the  latter  gives  forth  a  ''crack"  during  its  respon- 
sive movements  which  not  only  can  be  heard  by  the  patient  himself, 
but  also  by  the  examiner,  if  a  diagnostic  tube  be  employed.  Every 
otologist  must  have  frequently  seen  the  increased  redness  of  the 
anterior  superior  quadrant  of  the  drum-head,  owing  to  increased 
vascularity,  following  traction  upon  the  parts,  when  the  auricle  is 
drawn  upwards  and  backwards  to  facilitate  the  introduction  of  a 
speculum.  Very  gentle  traction  even  is  always  attended  with  more 
or  less  injection  of  the  manubrial  plexus  of  blood-vessels. 

Pulling  the  auricle  violently  is  no  less  cruel  than  boxing  the  ears, 
and  is  no  less  common;  the  lacerations  and  strains  caused  in  this 
manner  are  even  more  injurious  and  painful.  The  membranous  canal 
may  be  thus  lacerated,  and  since  the  deep  temporal  fascia  extends 
down  to  the  membrana  flaccida,  the  drum-head  also  is  often  lacerated. 

The  following  cases  illustrate  this  in  a  striking  manner: 

Case  1.— Male,  30  years  of  age.  Never  had  any  aural  trouble 
until  twelve  years  of  age.  when  an  English  teacher,  who  was  instruct- 
ing the  class  "on  the  endurance  of  Italians  to  pain,"  pulled  patient's 
left  auricle  to  test  his  endurance.  He  stood  the  torture  smilingly  as 
long  as  he  could,  when  the  teacher  became  angry  and  boxed  him  on 
the  left  ear,  knocking  him  down.  This  was  followed  by  ringing  and 
deafness  in  the  ear.  The  ear  has  troubled  him  off  and  on  ever  since, 
and  examination  shows  a  large  perforation  in  the  posterior-superior 
quadrant  of  left  drum-head  leading  up  into  the  attic  of  the  tympanum. 

Case  2. — Male,  29  years  of  age.  Five  years  ago  an  inmate  of 
Morris  Plains  Lunatic  Asylum  violently  pulled  his  right  auricle;  this 
was  followed  by  ringing  in  the  ear,  which  increases  whenever  he  has 
a  head  cold.  The  external  auditory  canals  are  so  narrow  at  the  osse- 
ous portion  that  drum-heads  cannot  be  seen. 

Cases.— Male,  10  years  of  age.  Always  subject  to  aural  inflamma- 
tion since  having  scarlet  fever  at  the  age  of  4.  One  week  ago,  the 
left  auricle  was  severely  pulled,  causing  a  wound  on  its  inner  surface 
and  giving  rise  to  pain  and  tinnitus  aurium. 

Case  4. — Female,  11  years  of  age.     While  playing  with  some  other 


WOUNDS    AND   INJURIES    OF    THE    DRUM-HEAD.  223 

children  in  front  of  a  shop,  the  proprietor  ran  out  and  seized  the 
patient  by  the  left  auricle  and,  during  her  struggles  to  escape,  the 
organ  was  violently  wrung  and  pulled.  She  cried  out  with  the  pain, 
which  continued  for  some  time;  a  discharge  appeared  the  next  day, 
and  she  was  brought  a  few  days  afterwards,  July  14th,  1884,  to  the 
New  York  Eye  and  Ear  Infirmary  for  relief.  An  examination  of  the 
ear  showed  that  the  integument  covering  the  superior  wall  of  the 
canal  and  the  upper  portion  of  the  drum- head  was  inflamed  and  ex- 
foliating, and  furthermore,  that  the  membrane  was  lacerated  in 
several  places  about  the  umbo.  There  was  a  discharge  through  the 
perforations  from  the  drum;  also  deafness  and  autophonia. 

The  patient  was  under  observation  for  about  seven  weeks,  after 
which  she  failed  to  return.  The  drum-head  had  not  then  healed  and 
a  purulent  discharge  from  the  ear  still  existed.  There  was  also  con- 
siderable deafness.  On  December  4th,  1887,  three  and  a  half  years 
after  the  injury,  this  patient  called  on  the  author,  stating  that  for  the 
past  two  or  three  weeks  she  had  had  a  good  deal  of  pain  and  discharge 
in  the  right  ear.  On  examining  the  left  (injured)  ear,  it  was  found 
that  the  drum-head  was  adherent  to  the  inner  wall  of  drum;  further- 
more that  a  white  cicatrix  was  present  behind  the  handle  of  the 
hammer,  which  was  drawn  backwards  somewhat.  The  malleus  was  dis- 
placed downwards.  Anteriorly  the  drum-head  had  a  little  brilliancy. 
Loud  ordinary  voice  could  be  heard  in  the  left  ear  at  twenty  feet  dis- 
tance. She  stated  that  the  left  ear  had  discharged  off  and  on  until 
four  months  ago;  that  there  was  tinnitus  resembling  musical  sounds 
and  intermittent  pain  in  the  same  ear.  She  left  off  going  to  school 
six  months  since,  as  she  was  so  deaf  that  she  could  not  understand 
what  the  teacher  said  to  her.  Patient  has  many  decayed  teeth.  She 
works  at  present  in  a  cigarette  factory. 

Case  5. — Male,  "^9  years  of  age.  Has  a  manometric  cicatrix  in  the 
drum-head  of  right  ear,  with  defective  hearing  and  autophonia.  The 
cicatricial  tissue  is  the  result  of  an  injury  received  when  he  was  nine- 
teen years  old.  Patient  had  been  angrily  ordered  from  his  seat  in  a 
carriage  and,  because  he  could  not  comply  quickly  enough,  his  uncle 
had  caught  hold  of  the  right  auricle  as  he  attempted  to  get  out, 
pulling  it  vigorously  afterwards.  Blood  flowed  from  the  ear  at  the 
time  and  continued  to  trickle  down  upon  his  clothing  for  an  hour. 
He  did  not  recover  for  several  weeks,  and  the  ear  was  occasionally 
the  seat  of  pain  for  some  years.  There  has  been  deafness  ever 
since,  and  very  distressing  autophonia,  due  to  the  manometric  cica- 
trix alluded  to  above. 

Case  6. — Male,  aged  14  years.  Three  months  ago,  his  brother 
caught  him  by  the  lobule  of  the  left  ear,  pulling  it  until  some  blood 
escaped  from  the  canal.  The  ear  has  discharged  ever  since  and  he 
only  hears  shouting  voice  in  that  ear.  The  left  drum-head  is  hyper- 
aemic,  the  inner  end  of  canal,  which  is  large,  is  red,  dry  and  exfo- 
liating. 

A  month  •  later,  when  patient  was  last  seen,  the  drum-head  had 
healed. 


224  WOUNDS    AND    INJURIES    OF    THE    DKUM-HEAU. 

Case  7. — Male,  37  years  of  age.  Fifteen  years  ago  had  his  right 
ear  severely  pulled,  causing  a  "click"  in  the  ear.  Pain  was  severe 
and  in  about  two  days  there  was  a  discharge  lasting  a  month.  Came 
on  account  of  neuralgic  pains  in  right  side  of  head  and  right  ear. 
There  is  no  cicatrix  iu  the  drum-head  to  indicate  the  site  of  any 
injury. 

Case  8. — Male,  23  years  old.  Two  days  ago,  left  auricle  was 
seized  by  the  teeth  of  a  man  during  a  fight.  The  lobule  was  much 
torn,  and  the  traction  made  on  the  auricle  lacerated  the  superior 
membranous  wall  of  the  canal,  where  it  enters  the  bony  portion. 
The  membrana  flaccida  was  also  lacerated  at  its  anterior  insertion. 
The  parts  were  still  bleeding,  and  the  neighborhood  very  much  in- 
jected.    There  was  no  deafness.     Patient  seen  but  once. 


8.     INJURY   TO    THE   DRUM-HEAD    FROM  VIOLENT   IN- 
FLATION CAUSING  SUDDEN  CONDENSATION 
OF  AIR  IN  THE  DRUM. 

The  strain  upon  the  drum-head  from  violent  inflation,  especially 
where  the  Eustachian  tube  is  abnormally  patulous,  sometimes  causes 
its  rupture.  This  may  occur  from  the  use  of  the  air- douche,  from 
blowing  the  nose,  coughing,  and  sneezing.  The  following  are  examples 
of  this  accident: 

Case  1. — Male  patient,  aged  51  years.  Several  days  before  com- 
ing for  treatment,  on  blowing  the  nose  violently,  heard  air  escape  from 
the  left  ear.  Two  or  three  days  later  on,  there  was  much  pain  in  the 
ear  with  hemicrania  of  the  left  side  and  pain  in  the  left  temporo- 
maxillary  articulation  on  mastication;  a  discharge  from  the  ear  soon 
occurred  and  now  continues.  The  exact  seat  of  the  perforation  can- 
not be  located  on  account  of  the  swelling  and  secretion  present. 

Case  2. — Male,  aged  9  years.  Patient  had  recently  recovered  from 
acute  purulent  inflammation  of  the  right  ear,  a  large  perforation  being 
closed  by  cicatricial  tissue.  Valsalvan  experiment  caused  rupture  of 
the  newly-formed  closure.     Discharge,  however,  did  not  return. 

He  was  advised  to  avoid  blowing  the  nose,  and,  on  his  returning 
some  months  afterwards,  the  perforation  was  found  to  have  closed 
up  again. 

Case  3. — Male,  aged  33.  Is  a  consumptive  and  has  nasal  hemor- 
rhages. Three  weeks  before  coming  he  had  sniffed  up  a  warm  solution 
of  alum,  and  commenced  blowing  the  nose  when  he  felt  something 
snap  in  the  right  ear;  ever  since  there  has  been  autophonia,  tin- 
nitus, and  pain  in  the  ear,  the  latter  extending  to  the  vertex  and  down 
the  neck.  There  is  a  feeling  of  soreness  about  the  auricle.  The  right 
drum-head  and  adjacent  portion  of  the  external  auditory  canal  are 
acutely  inflamed  and  desquamating,  but  the  perforation  cannot  be 


WOUNDS    AND   INJURIES    OF   THE    DRUM-HEAD.  225 

seen.     He  is  deaf  in  the  affected  ear  to  voice  spoken  below  ordinary 
tone  close  by  the  ear. 

Case  4. — Male,  43  years  of  age.  During  severe  paroxysms  of  cough- 
ing "  felt  something  turn  in  the  left  ear/'  and  afterwards  there  was 
severe  pain  in  the  left  temporal  region  for  twenty-four  hours.  The 
tinnitus  existing  at  first  has  ceased,  but  there  is  yet  decided  auto- 
phonia.  Examination  showed  a  perforation  in  left  drum-head  (which 
was  hyper^mic)  just  below  the  umbo.     There  was  no  discharge. 

Case  5. — Male,  64  years  of  age.  Is  rheumatic,  and  has  long  had 
deafness  in  the  left  ear.  On  swallowing,  there  is  always  a  "squeak- 
ing" sound  experienced  in  the  left  ear.  Whilst  coughing  violently 
last  winter,  something  was  felt  to  give  way  in  the  left  ear,  and  deafness 
and  tinnitus  were  increased.  Examination  shows  a  recently  formed 
cicatrix  in  posterior  segment  of  left  ear,  partially  closing  the  rupture, 
but  there  is  no  perforation  whistle  on  inflation. 

Case  6. — Male,  34  years  of  age.  Was  recently  the  subject  of  acute 
catarrhal  inflammation  of  the  right  middle  ear;  on  violently  blowing 
the  nose,  sudden  pain  was  experienced  in  the  affected  ear  and  side  of 
the  head,  with  ringing  noises  and  a  perforation  whistle. 

These  cases,  familiar  to  otologists,  are  very  often  met  with,  and 
examples  might  be  cited  ad  inHnitum,  but  the  above  will  serve  to 
impress  the  reader  with  the  importance  of  cautioning  all  patients, 
to  avoid  blowing  the  nose  violently  while  healing  of  the  drum- 
head is  taking  place.  It  is  obvious,  of  course,  that  the  meddlesome 
practice  of  inflation  of  the  drum  by  any  method  should  be  avoided  at 
this  time. 

Bloivs  upon  the  nose  may  cause  sudden  condensation  of  air  in  the 
drum.  For  example,  a  male,  44  years  of  age,  run  down  and  of  dissi- 
pated habits,  received  a  severe  blow  upon  the  nose  two  months  ago, 
causing,  as  he  alleges,  fracture  of  the  nasal  bones.  Soon  after  there 
was  buzzing  and  deafness  in  the  left  ear.  Three  weeks  later  on,  there 
was  pain  over  the  whole  temporal  region,  and  in  about  two  weeks 
more  swelling  appeared  over  the  mastoid  process.  The  swelling  con- 
tinued for  three  weeks,  when  it  was  found  that  an  abscess  had  formed. 
The  pus  was  evacuated.  The  drum-head,  on  examination,  showed 
evidences  of  inflammation  of  the  attic  of  the  tympanum;  secretions, 
however,  did  not  escape  through  the-  drum-head,  but  escaped  by 
burrowing  underneath  the  integument,  finally  forming  the  post-aural 
abscess.  Patient  recovered  in  about  five  weeks.  The  following  case 
is  also  of  interest  in  this  connection: 

Male,  40  years  of  age.     Twelve  years  ago,  while  laying  back  in  a 
barber's  chair  to  be  shaved,  a  friend,  in  sport,  dashed  a  soap  brush 
filled  with  lather  forcibly  up  against  his  nose.     This  caused  a  feeling 
15 


226  WOUNDS   AND    INJURIES    OF   THE    DKUM-HEAD. 

of  distress  in  the  nose,  and  after  sneezing  and  blowing  the  nose  freely 
to  obtain  relief,  he  "felt  something  go  up  to  right  ear," causing  much 
pain.  An  hour  after  the  accident,  the  pain  increasing,  he  went  to  a 
drug-store  where  chloroform  was  instilled  into  the  ear,  greatly  in- 
creasing his  suffering.  The  pain  continued  for  a  couple  of  days,  and 
the  ear  soon  got  well.  Two  years  ago,  however,  a  friend,  in  play, 
slapped  him  on  the  same  ear  with  the  open  hand,  when  he  *'felt  the 
air  violently  forced  into  his  head."  The  ear  was  tender  for  a  few 
days,  but  there  was  no  tinnitus  or  discharge.  The  patient  gave  a 
history  of  syphilis,  and  has  been  in  a  private  asylum  for  inebriates. 
For  two  or  three  months  there  has  been  distressing  tinnitus  and  great 
deafness  in  the  right  ear,  the  drum-head  of  which  has  large  opacities. 

For  information  concerning  injuries,  etc.,  to  the  ear  arising  from 
diving,  caissons,  tunnels,  etc.,  the  reader  may  consult  chapter  XIX. 


CHAPTER    XI. 

REMAEKS   ON    THE  ANATOMY   OF    THE   MIDDLE   EAR. 

Before  entering  upon  a  description  of  the  diseases  of  this  region,  a 
brief  but  practical  review  of  the  anatomy  of  the  middle  ear  is  given 
at  this  place  for  convenience  of  reference. 

According  to  Leidy/  the  auditory  plate"^  iornis  a  broad  archway  be- 
tween the  mastoid  and  post-glenoid  process,  and  extends  inwardly  as 
the  roof  of  the  external  auditory  meatus  in  the  adult.  "  The  inner 
extremity  defines  the  meatus  from  the  tympanic  cavity  by  an  acute 
curved  ridge,  from  which  a  wide  crescentoid  plate,  the  tympanic 
scute,  slants  upward,  and  forms  the  outer  boundary  of  the  upper 
portion  of  the  tympanic  cavity.  The  scute  is  separated  externally 
from  the  rest  of  the  auditory  plate  by  a  spongy  substance,  but  occa- 
sionally is  continuous  through  thick,  compact  substance.  Its  anterior 
border  joins  the  tympanic  segment,  and  its  posterior  border  is  contin- 
uous with  the  spongy  substance  of  the  outer  wall  of  the  mastoid 
antrum. " 

"  The  inner  surface  of  the  mastoidea  forms  part  of  the  posterior 
cranial  fossa.  Contiguous  to  the  petrosa,  it  is  impressed  by  the  large 
curved  channel  for  the  lateral  sinus." 

A  portion  of  the  anterior  surface  of  the  petrosa  constitutes  the 
tegmen,  a  wide  triangular  plate  covering  the  tympanum,  the  mastoid 
antrum,  and  the  beginning  of  the  Eustachian  tube.  "The  under 
part  of  the  tegmen  is  commonly  formed  by  a  layer  of  spongy  substance 
of  variable  thickness,"  says  Leidy,  and  its  upper  surface  is  "  more  or 
less  defined  by  a  fissure,  remaining  as  part  of  the  petro-squamosal 
suture  which,  at  birth,  extends  from  the  notch  at  the  bottom  of  the 
squamosa  to  that  of  its  upper  border.  Frequently,  also,  a  vascular 
groove,  and  several  foramina  for  the  transmission  of  vessels,  mark  the 
line  of  separation." 

'  A  Study  of  the  Human  Temporal  Bone.    Science.    May  and  June,  1888. 
^  Lamina  auditoria. 


228 


ANATOMY  OF   THE   MIDDLE    EAR. 


The  tympanic  cavity  is  divided  by  Leidy  into  two  portions:  ''the 
main  chamber,  which  may  be  named  the  atrium,  situated  directly 
opposite  the  external  auditory  meatus;  and  a  recess  above  this,  which 
may  be  distinguished  as  the  attic."  The  atrium  to  superficial  obser- 
vation has  been  too  often  regarded  as  constituting  the  tympanum, 
but  of  far  greater  importance  to  the  otologist  is  the  attic,  which  lies 
above  the  point  blank  range  of  vision  in  inspecting  the  middle  ear. 
The  attic '  of  the  tympanum,  pyramidal  in  shape,  is  situated  over  the 
atrium,  and  above  the  tympanic  orifice  of  the  external  auditory 
meatus.  It  is  separated  from  the  cranial  cavity  by  the  tegmen.  "  Its 
inner  boundary  is  a  convex  prominence  produced  by  the  contiguous 
portions  of  the  external  semi-circular  and  facial  canals.     Its  outer 


Fig.  39. 


Fig.  39. — ^View  from  within  of  the  outer  Portion  of  the  left  temporal  Bone,  sawed 

THROUGH  THE  TYMPANUM,  FORE  AND  AFT,  PARALLEL  WITH  ITS  INCLINATION    (FROM  LeIDY). 

A,  tympanic  margin  of  the  external  auditory  meatus,  formed  below  and  at  the  sides  by  the 
grooved  margin  of  the  tymj)anic  plate,  and  above  by  the  margin  of  the  auditory  plate  ;  B, 
scute,  forming  the  outer  boundary  of  the  attic  ;  C,  tegmen  ;  D,  mastoid  antrum  ;  E,  promi- 
nence of  the  inner  posterior  boundary  of  the  attic  ;  JF",  canal  for  the  accommodation  of  the  long 
process  of  the  mallet ;  O,  j>etro-squamosal  Assure.  Below  E  are  seen  the  pyramid  and  the  aper- 
ture of  the  tympanic  cord. 

Fig.  40.— Section  of  the  left  temporal  Bone  through  the  Squamosa,  noiEDiATELY  in  ad- 
vance OF  THE  EXTERNAL  AUDITORY  MEATUS  (FROM  IiEIDY). 

A,  atrium  of  the  tympanum  ;  B,  prominence  on  the  inner  back  part  of  the  attic  ;  C,  scute  at 
the  outer  part  of  the  attic  ;  D,  auditory  plate  ;  E,  tegmen  ;  F,  mastoid  antrum  ;  G,  anterior 
passage  of  the  same  ;  H,  canal  for  the  long  process  of  the  mallet ;  I,  hiatus  of  the  facial  canal ; 
J,  Eustachian  tube. 

boundary  is  the  wide  crescentic  tympanic  scute  of  the  auditory  plate. 
It  opens  above  the  prominence  of  its  inner  boundary,  outward  and 

'  "  AtticuB  tympanicus,  upper  chamber  of  the  tympanum  of  Huxley." 


ANATOMY   OF   THE   MIDDLE   EAR.  229 

backward,  by  a  large  aperture '  into  the  mastoid  antrum.  Beneath, 
it  opens  into  the  atrium  by  an  elliptical  aperture,  formed  internally 
by  the  ridge  of  the  facial  canal,  and  externally  by  the  tympanic 
margin  of  the  auditory  plate.  The  attic  is  partially  occupied  by  the 
mallet  and  anvil,  which  thence,  by  the  handle  of  the  former  and  the 
long  process  of  the  latter,  extend  into  the  atrium." 

"  The  mastoid  antrum  is  a  prolongation  of  the  attic  backward  and 
outward  in  the  spongy  substance  of  the  mastoidea.     It  is  of  variable 


Fia.  41.— Cast  of   Eustachian  tube  and  Middle  ear,  showing  the  radiation   of    thk 

CELLULES  SPRINGING  FROM  THE  ANTRUM  (FROM  BeZOLD  *  ). 

1.  Isthmus  tubae.  2.  Roof  of  the  tympanum.  3.  Incisura  transversalis.  4.  Sinus  tympani 
(Steinbrugge).  5.  Niche  of  the  fenestra  rotunda.  6,  6.  Cellules  radiating  backwards  and 
downwards  from  the  antrum. 

size,  ordinarily  ranging  from  that  of  the  attic  to  double  the  dimen- 
sions of  this.  It  sometimes  ends  in  a  blunt  flask-like  recess,  but  is 
oftener  more  or  less  extended  downward  among  the  cellules  of  the 
mastoid  process.  Frequently  it  gives  off  a  smaller  fork  or  passage, 
■which  is  directed  outward  and  upward  among  the  cellules  above  the 
external  auditory  meatus;  and  rarely  a  third  branch  is  directed  more 
anteriorly. ''     (See  Fig.  41.) 

'  "  Petro-mastoid  canal  of  Sappey." 
'^  Corrosions-Anatomie. 


230 


ANATOMY    OF   THE   MIDDLE    EAR. 


"  While  the  atrium  of  the  tympanum  varies  but  little  in  size,  the 
attic  and  mastoid  antrum  vary  greatly." 

"  The  mastoid  cellules  consist  of  air  cavities  of  variable  number, 
size,  and  extent  in  the  midst  of  the  spongy  substance  of  the  mastoidea. 
They  are  commonly  more  or  less  pronounced  in  number  and  size  with 
age.  With  the  advance  of  years,  they  increase  in  both  respects  from 
the  conversion  of  the  ordinary  marrow-filled,  spongy  substance  into 
vacant  spaces.  Later,  they  increase  in  capacity  by  expansion  and 
coalescence,  and  proportionately  decrease  in  number;  and  often  in  old 
age  some  of  them  even  exceed  in  size  the  antrum.  The  cellules  com- 
municate with  one  another  and,  through  the  sides  and  extremity,  with 


Fig.  42.— View  from  within  of  the  right  Tympanum  and  contiguous  Parts  (from  Henlk). 

Tt,  Tt\  tensor  tympani ;  Mcp,  head  of  the  hammer  ;  *  handle  of  the  same  ;  lb,  short,  11, 
long  process ;  Ipl,  lenticular  proces  of  the  incus  ;  /,  chorda  tympani ;  2,  septum  tubee  ;  3, 
tube ;  4,  drum-head. 


the  mastoid  antrum."    They  are  separated  from  the  lateral  sinus  by  a 
thin  plate  of  bone  only. 

If  now  we  carefully  remove  the  iegmen  in  the  recent  subject,  and 
look  down  upon  the  parts  thus  exposed  to  view,  we  shall  find  the 
attic  and  antrum  in  situ,  and  everywhere  lined  with  mucous  mem' 
brane.  The  attic  is  divided  by  the  incus  and  malleus,  which  are 
placed  across  it  fore  and  aft,  into  an  outer  and  inner  apartment  ;  they 
only  partially  occupy  it,  and  the  long  process  of  the  former  and  the 
handle  of  the  latter  project  down  into  the  atrium.  The  two  attic 
apartments,  of  which  the  inner  is  much  the  larger,  communicate  more 
or  less  freely  with  each  other  overhead,  with  the  atrium  below,  the 
Eustachian  tube  in  front,  and  the  antrum  behind. 


ANATOMY  OF  THE  MIDDLE  EAR.  231 

The  outer  apartment  is  wedge-shaped,  wider  above  and  gradually 
becoming  narrower  below,  where  the  body  of  the  anvil  and  neck  of 
the  mallet  lie  almost  in  contact  with  the  margin  of  the  auditory  plate. 
The  bottom  communicates  anteriorly  and  posteriorly  with  the  atrium 
by  a  very  narrow  slit. 

The  inner  apartment  communicates  much  more  freely  with  the 
atrium,  but  the  passage  is  contracted  by  the  prominence  before  alluded 
to  on  its  inner  wall,  the  impingement  of  the  anvil  and  mallet,  the 
chorda  tympani,  ligaments,  and  folds  of  mucous  membrane.  (See 
Pig.  43.) 

Anatomy  of  the  Child's  Ear, — At  birth  the  tympanum  and  mastoid 
antrum,  also  the  ossicula,  are  about  as  large  as  they  ever  become  in 
adult  life ;  the  petro-squamosal  suture  is  but  imperfectly  closed,  its 
external  portion  being  anchylosed  only  near  the  time  of  birth,  and  is 
usually  not  obliterated  until  the  end  of  the  first  or  second  year  of  life. 
It  is  always  well  marked  in  infancy  and  often  remains  imperfectly 
closed  throughout  life. 

*'  The  mastoid  process,  scarcely  marked  at  birth,  becomes  conspic- 
uous only  after  a  year  or  two.  The  mastoid  antrum  is  developed  at 
birth  ;  but  the  surrounding  mastoid  cellules  undergo  but  little  devel- 
opment until  after  puberty." 

"  The  external  auditory  meatus  is  produced  after  birth.  The  audi- 
tory plate  forming  its  roof  is  gradually  more  differentiated  from  the 
rest  of  the  squamosal,  and  its  tympanic  scute  becomes  more  distinct 
by  production  of  spongy  substance  between  it  and  the  roof  of  the 
meatus."  '  The  tympanic  orifice  is  formed  by  the  smooth  auditory 
plate  above  which  constitutes  about  one-fourth  of  this  bony  circle  and 
to  which  the  superior  border  of  the  drum-head  is  attached  ;  the  lower 
three-fourths  is  formed  by  the  annulus  tympanicus — a  distinct  plate 
of  bone  at  birth,  but  afterwards  forming  the  tympanic  plate. 

The  manner  in  which  the  drum-head  attaches  itself  to  this  orifice  is 
of  great  interest  in  connection  with  inflammation  of  the  attic.  Supe- 
riorly the  membrana  flaccida  is  loosely  connected  with  the  upper  mar- 
gin of  the  aperture  (where  the  annulus  tympanicus  is  wanting)  over 
which  it  passes  to  become  continuous  with  the  lining  of  the  upper  wall 
of  the  external  auditory  canal  ;  the  entire  surface  of  the  auditory 
plate  being  smooth,  this  integument  glides  over  it  with  considerable 
freedom.  The  membrana  flaccida  is  much  more  distensible  than  the 
membrana  vibrans,  which  latter  portion  of  the  drum-head  is  more 
firmly  fixed  into  the  grooved  lower  three-fourths  of  the  circle. 

'  Quotations  are  from  Leidy,  loc.  cit. 


232  ANATOMY    OF   THE   MIDDLE    EAR. 

Under  the  pressure  of  retained  fluids  in  the  attic,  the  membrana 
flaccida  and  membranous  wall  of  the  adjacent  canal  are  easily  de- 
tached. 

The  auricle  and  canal  of  the  infant  are  soft  and  flabby  ;  the  former 
is  not  flrmly  fixed  to  the  head  and  may  be  moved  freely  in  all  direc- 
tions about  its  attachment ;  the  walls  of  the  latter  lie  in  contact,  the 
superior  wall  being  the  longest.  The  canal  and  drum-head  are  covered 
at  birth  with  smegma,  the  removal  of  which  by  wiping  may  also  de- 
tach the  superficial  epithelial  layer.  Tension  requisite  to  the  perform- 
ance of  its  functions  does  not  yet  exist  in  the  transmitting  mechanism, 
and  hearing  apparently  is  slight. 

The  horizontal  plane  of  the  drum-head  at  this  period  is  favorable 
to  the  occurrence  of  injury  from  the  mere  gravitation  of  fluid  in  the 
drum,  and  when  distention  occurs  in  consequence  of  profuse  secre- 
tion into  the  atrium  it  gives  way  readily. 

The  canal  for  the  facial  nerve  lies  like  a  ridge  along  the  whole 
breadth  of  the  inner  wall  of  the  tympanum  just  above  the  promon- 
tory ;  this,  and  the  margin  of  the  auditory  plate  opposite,  limits  the 
passage  between  the  atrium,  tympanicum  and  the  atticus  tympanicus. 
The  boundary  is  further  restricted  by  foldings  of  the  mucous  lining 
of  the  tympanum  in  adapting  itself  to  the  chorda  tympani.  In  the 
normal  state,  drainage  from  the  attic,  as  well  as  from  the  atrium,  is 
afforded  by  the  debouchure  of  the  Eustachian  tube  anteriorly.  The 
attic  has  a  pretty  free  outlet  into  the  atrium  behind  the  descending 
ramus  of  the  incus,  since  a  hiatus  exists  between  this  ossicle  and  the 
posterior  wall  of  the  tympanum ;  but  the  descent  of  the  malleus 
handle  and  long  process  of  the  incus  between  these  two  outlets  natu- 
rally encroaches  upon  the  passage  from  the  attic  to  the  atrium. 


^>\ 


CHAPTEE  XII. 

OTITIS  MEDIA  NON-SUPPUEATIVA. 

Acuta  ;   Subacuta  ;    Serosa  ;  Chronica  ;    Syphilitica. 

OTITIS   MEDIA  ACUTA. 

Otitis  media  acuta  is  an  inflammatory  process  of  the  mucous  and 
submucous  lining  of  the  middle  ear,  having  a  very  decided  tendency 
to  stop  short  of  purulency.  Thus  a  susceptible  person  may,  after 
exposure  to  certain  vicissitudes,  take  a  severe  cold  in  the  head,  as  it 
is  called,  and  after  a  few  hours  or  days,  as  the  case  may  be,  a  feeling 
of  stuffiness  in  the  ears  with  deafness  and  pain  comes  on  ;  sometimes 
one  or  the  other  of  these  symptoms  is  not  severe.  In  the  more  pro- 
nounced cases,  the  trouble  is  ushered  in  with  fever  preceded  by  chills. 
The  writer  has  often  seen,  on  examining  a  case  of  this  kind,  a  dis- 
charge emerging  through  a  perforation  in  the  drum-head  of  one  ear, 
whilst  inspection  of  the  other  drum-head  only  presented  an  inflamed 
condition,  which,  when  observed  from  day  to  day,  would  be  found  to 
gradually  clear  up,  the  organ  regaining  its  normal  functions ;  the 
latter  is  a  case  of  acute  otitis  media.  Sometimes  one  ear  only  is 
affected  with  acute  inflammation ;  but  often  both  are  invaded  at  the 
same  time,  or  within  a  few  hours  or  days  of  each  other.  A  regressive 
course,  where  no  causative  influence  remains  active,  begins  in  a  short 
time  and  the  trouble  usually  soon  disappears.  There  are,  however, 
important  exceptions  to  this  rule,  especially  in  children,  where  recur- 
rent exacerbations  may  ensue  from  time  to  time.  In  certain  instances, 
the  trouble  passes  into  a  subacute  form  which  may  continue  a  long 
time.  Acute  inflammation  of  the  middle  ear  most  frequently  occurs 
in  the  course  of  a  severe  head  cold,  or  from  the  reflected  irritation  in 
dental  caries  or  dentition,  rhinitis,  the  unskilful  application  of  the 
cautery,  acids,  or  the  snare  to  the  turbinated  bones,  and  the  like  ;  it 
is  more  particularly  liable  to  inflammation  from  these  influences  during 
the  existence  of  a  head  cold.  The  pain  experienced  is  not  always 
due  to  pent-up  secretions,  but  may  be  reflected  (otalgia),  especially 


234  OTITIS   MEDIA   ACUTA. 

in  cases  where  the  patient  has  dental  trouble  at  the  same  time. 
Thus  patients  often  apply  for  treatment  on  account  of  pain  which 
they  ascribe  to  the  ear  alone,  and  where,  on  examination,  this  organ 
will  show  no  sign  of  inflammation,  the  seat  of  the  disturbance  being 
found  in  the  teeth. 

Etiology.  As  regards  age  and  causation,  children  between  the  second 
month  and  the  end  of  the  second  year  are  obnoxious  to  reflex  irrita- 
tion, due  to  first  dentition,  mal-nutrition,  or  dyscrasia,  the  exanthem- 
ata, and  inflammation  of  the  upper  air-tract.  Between  the  ages  of 
four  and  fifteen  years,  the  same  causes  are  active  ;  second  dentition 
giving  rise  to  as  much  or  even  greater  disturbance  than  first  denti- 
tion, catarrhal  affections  continuing,  with  the  greater  frequency  of 
hypertrophied  tonsils.  In  childhood,  furthermore,  traumatism  from 
blows  on  the  ear,  undue  force  exerted  in  the  removal  of  foreign 
bodies  from  the  organ,  the  entrance  of  sea-water  into  the  ear  in  bath- 
ing, the  use  of  the  nasal  douche,  etc.,  is  of  occasional  occurrence. 

No  account  of  the  predisponents  of  this  or  any  other  aural  trouble 
would  be  complete  without  allusion  to  the  disturbances  of  the  diges- 
tive and  sexual  functions,  and  the  nervous  exhaustion  consequent 
on  their  abuse  or  perversion.  Females  subject  to  uterine  disturbances 
are  usually  neurasthenic  and  consequently  highly  sensitive  to  vicissi- 
tudinous  environments ;  as  are  also  over-worked  persons  of  both  sexes, 
whose  hygienic  surroundings  are  bad.  Putting  aside  the  question  of 
premature  and  exhaustive  sexual  activity  in  persons  from  puberty  to 
adolescence,  the  writer  finds  that  among  his  cases  ranging  from  the 
sixteenth  to  the  twenty-first  years  of  life,  phthisis,  the  result  of  ex- 
posure, frequently  influenced  the  course  of  the  disease  and  that  sea- 
bathing was  the  exciting  cause  much  more  often  than  at  an  earlier 
age.* 

From  the  age  of  twenty-three  to  thirty-five  years  inclusive,  rhinitis, 
intemperance,  abortion  and  other  genital  disturbances,  the  contami- 
nation of  phthisis  or  syphilis,  the  irritation  from  the  difficult  eruption 
of  wisdom  teeth,  caries  of  the  teeth,  etc.;  the  direct  injury  from  sea- 
bathing, the  use  of  the  nasal  douche,  snuffing  up  salt  water  and  other 
solutions  ;  the  unfavorable  infiuences  of  mental  worry  and  defective 
hygiene  were  all  found  to  be  important  causative  agencies. 

Patients  between  the  ages  of  thirty-six  and  forty-six  years  were  in- 
fluenced by  similar  causes.  Among  females,  however,  the  meno- 
pause at  this  age  exerts  an  unfavorable  influence  in  certain  cases. 

'  Causative  agents,  as  over- work,  crowding,  sea-bathing,  etc.,  of  course 
apply  more  particularly  to  the  inhabitants  of  large  cities. 


OTITIS   MEDIA   ACUTA. 


235 


The  following  table  gives  the  ages  and  sex  of  384  cases  of  acute 
non-suppurative  inflammation,  from  which  the  above  etiological  data 
were  derived : 


Age. 

Under  one  year  of  age 

Between  1  and  2  years 

Between  2  and  3  years 

Between  3  and  4  years 

Between  4  and  5  years 

Between  5  and  10  years . . . . 
Between  10  and  20  years. . . 
Between  20  and  30  years. . , 
Between  30  and  40  years. . . 
Between  40  and  50  years. . . 
Between  50  and  60  years. . . 
Between  60  and  70  years  , . 

Total ' 


Males. 


232 


Females.     Total 


2 

2 

4 

1 

1 

1 

2 

8 

8 

8 

6 

4 

3 

7 

16 

26 

42 

59 

20 

79 

62 

27 

89 

46 

18 

64 

24 

11 

35 

9 

4 

13 

5 

•• 

5 

116 


348 


The  ages  of  the  infants  under  one  year  were  as  follows  :  one  6 
months  (male)  ;  one  7  months  (female) ;  one  8  months  (male),  and 
one  9  months  (female). 

Objective  Symptoms.  The  external  auditory  canal  does  not 
always  show  evidences  of  the  presence  of  inflammatory  action  in  the 
tympanum  ;  but  in  the  more  severe  cases  of  acute  otitis  media  the 
dermic  or  periosteal  layers  of  the  canal  may  be  involved  by  extension 
of  the  inflammatory  process  through  continuity.  The  canal  is,  how- 
ever, rarely  so  much  swollen  as  to  prevent  an  inspection  of  the  drum- 
head. It  is  indeed  but  seldom  that  vascular  disturbance  about  the 
ear  does  not  also  involve  the  mallear  plexus,  and  an  increased  vascu- 
larity of  this  latter,  togetlier  with  congestion  of  the  membrana 
flaccida,  especially  behind  the  malleus,  are  the  most  frequent  changes 
observable.  Where  the  inflammation  is  chiefly  conflned  to  the  attic, 
the  appearances  just  alluded  to  are,  for  the  most  part,  very  well 
marked,  and  under  the  pressure  of 'secretions  the  membrana  flaccida 
may  bulge  out.  But  where  the  atrium  is  the  principal  seat  of  the 
trouble,  the  membrana  vibrans  will  also  be  found  distended  and  very 
red,  which  appearance  sometimes  continues  for  days  before  regression 
is  established.  Blebs  on  the  drum-head  are  not  of  uncommon  occur- 
xence. 

When  inflammation  begins  in  the  attic,  the  atrium  is  seldom  greatly 
involved,  and  the  reverse  of  this  may  hold  good.  Both  attic  and 
.atrium  are,  however,  frequently  affected  at  the  same  time. 

After  a  regressive  course  has  been  established,  the  drum-head  often 


236  OTITIS    MEDIA    ACUTA. 

undergoes  a  process  of  desquamation,  its  dermic  layer  becoming  thus 
detached. 

Subjective  Symptoms  and  Course.  The  prominent  subjective  symp- 
toms of  acute  inflammation  of  the  middle  ear  are  pain,  often  severe, 
deafness,  noises  in  the  ear  (tinnitus),  and  autophonia  (see  Chapter 
XVI.);  where  the  attic  is  principally  affected,  the  degree  of  deafness 
is  generally  much  loss  than  where  the  atrium  alone  is  the  seat  of  the 
disturbance. 

A  feeling  of  '^ numbness'^  is  a  symptom  often  complained  of  by 
these  patients,  a  phenomenon  possibly  due  to  the  benumbing  of  the 
nerves  about  this  region  from  the  inflammation  or  the  pressure  of  the 
swollen  tissues.  Such  patients  often  say  that  they  experience  "  dumb- 
ness," an  autophonous  phenomenon. 

In  uncomplicated,  non-perforative  (non-purulent?)  inflammation 
of  the  middle  ear  tract,  in  which  the  mucous  membrane  of  the  tym- 
panum (atrium  and  attic),  mastoid  antrum,  and  pneumatic  cellules  of 
the  mastoid  may  all  be  more  or  less  involved,  recovery  is,  in  healthy 
subjects,  speedy,  and  but  little,  if  any,  deafness  may  remain.  Even 
large  quantities  of  mucous  or  setous  matter  are  speedily  reabsorbed. 
In  run-down  subjects,  however,  the  mucous  membrane  is  liable  to 
remain  thickened,  or  tough  mucus  may  not  be  absorbed;  in  such 
cases  defective  hearing  and  tinnitus  may  be  more  or  less  permanent. 
In  certain  subjects  infiltration  of  the  tissues  rapidly  takes  place,  caus- 
ing sudden  and  profound  deafness  from  fixation  of  the  ossicles,  es- 
pecially in  syphilitic  patients.  The  most  marked  non-syphilitic  ex- 
amples the  writer  has  seen  were  in' persons  residing  in  the  tropics. 
Two  cases  among  the  latter  are  particularly  instructive. 

Case  1. — A  gentleman,  aged  45  years,  came  to  the  writer  in 
1882  with  the  following  history.  He  had  resided  in  Rio,  Brazil,  some 
thirteen  years  altogether,  having  taken  in  the  mean  time  two  vaca- 
tions of  eighteen  months  each,  during  which  he  visited  Europe  and 
this  country.  During  his  residence  in  the  tropics,  he  was  for  some 
time  under  severe  mental  strain,  but  passed  the  warm  season  in  the 
mountains  of  Petropolis,  the  summer  residence  of  the  court,  at  an 
elevation  of  some  three  thousand  feet.  "While  so  run  down,  the  ex- 
treme and  sudden  variations  in  temperature  were  very  trying;  suc- 
ceeding to  intensely  hot  and  dry  days,  were  damp  nights  some  20° 
Fahrenheit  cooler.  Not  having  learned  of  the  perils  of  el  sereno,  the 
fatal  night  air,  he  was  less  prudent,  in  respect  to  exposure  after  sun- 
down, than  the  natives  (who  are  careful  to  protect  themselves  with 
warmer  clothing,  and  avoid  uncovering  the  head  needlessly  for  a 
moment  even),  and  finally  contracted  severe  head  catarrh.  There  was, 
at  first,  a  sense  of  great  heat  and  discomfort  in  the  nose,  perversion 
of  the  sense  of   smell,  especially  on   rising  in  the   morning,    when 


OTITIS   MEDIA    ACUTA.  237 

everything  had  the  odor  of  "burnt  meat."  There  was  soon  a  profuse 
down-pour  of  fluid  from  the  head,  mixed  with  blood.  On  the* 
frontal  sinuses  and  other  cavities  becoming  invaded,  the  head  felt 
"  hot  and  dry."  These  symptoms  continued  for  some  time.  The  ears 
were  early  iavolved,  and  as  the  disease  progressed  he  became  rapidly 
very  deaf .  Distressing  tinnitus  accomi3anied  the  other  symptoms.  He 
was  for  a  few  days  so  deaf  as  to  be  unable  to  converse,  but  before 
long  some  improvement  took  place;  there  was  no  marked  improve- 
ment in  the  head  catarrh,  however,  until  he  left  the  tropics;  and  when 
seen  subsequently,  he  could  converse  with  difficulty,  in  an  ordinary 
tone  of  voice,  at  a  distance  of  six  or  eight  feet.  Under  the  more 
favorable  influences  of  the  climate  in  New  York,  he  improved  very 
much  under  treatment. 

The  next  case  is  similar  to  the  above. 

Case  2. — An  English  gentleman,  35  years  of  age,  residing 
in  Venezuela.  This  patient,  a  person  very  much  over-worked,  in 
April,  1884,  made  a  three  weeks'  journey  into  the  interior  of  the 
countiy,  during  which  he  was  much  exposed  to  an  almost  continuous 
rain-storm.  He  escaped  the  prevailing  fever  as  he  had  done  liitherto, 
during  twelve  years'  residence  in  tropical  South  America.  During 
his  stay  with  a  friend  in  the  country,  he  sat  one  morning  after  break- 
fast in  the  corridor  or  the  house  without  any  coat.  After  dinner,  the 
same  day,  while  engaged  in  conversation,  he  suddenly  had  a  most 
profuse  flow  of  fluid  from  both  nostrils  and  the  eyes,  which  lasted  for 
some  hours.  The  attack  was  severe  and  was  accompanied  with  much 
coughing.  It  was  feared  that  this  would  prove  to  be  a  precursor  of 
the  "fever "of  the  country,  but  the  more  disagreeable  symptoms 
passed  off  by  the  next  monring.  Head  catarrh,  however,  continued., 
the  tympanum  became  affected,  and  there  was  almost  total  deafness. 
A  disagreeable  sense  of  fulness  in  the  head,  and  dryness  of  the  upper 
air-tract,  characterized  the  course  of  the  disease  and,  in  fact,  still  re- 
mained when  the  writer  was  consulted. 

Treatment.  The  treatment  of  otitis  media  acuta,  or  non-perfora- 
tive  inflammation  of  the  middle  ear,  includes  remedies  for  the  relief 
of  earache,  which  is,  especially  in  children,  a  prominent  symptom. 
Since  the  more  serious  cases  usually  occur  from  neglect  or  meddle- 
some treatment  in  subjects  run  down  from  some  cause  or  other,  fixed 
rules  for  guidance  in  any  particular  instance  cannot  be  laid  down. 
Each  case  must,  to  a  great  extent,  be  regarded  as  an  individual  prob- 
lem requiring  special  consideration. 

The  administration  of  minute  doses  of  mercury  is  reputed  to  exer- 
cise a  beneficial  infiuence  in  infiammation  of  mucous  surfaces,  and, 
since  the  subjects  of  mucous  catarrh  are  liable  to  have  gastric  de- 
rangements at  the  same  time,  the  practice  seems  well  founded.  The 
writer  often  employs  some  form  of  the  drug  in  trituration  tablet  form, 


238  OTITIS  mp:dia  acuta. 

in  doses  of  ^V  ^^  iw  of  ^  grain  every  three  or  four  hours,  according 
to  circumstances. 

In  some  instances,  the  calx  sulphurata  administered  in  the  same 
manner  seems  to  give  good  results.  Vascular  and  nervous  excite- 
ment, usually  attended  with  more  or  less  pain  and  swelling  about  the 
ear,  may  be  controlled  by  aconite,  belladonna,  gelsemium,  pulsatilla 
and  other  drugs  of  similai^  action.  Unendurable  pain  calls  for  the 
administration  of  decided  but  tentative  doses  of  morphine. 

In  certain  cases  much  relief  may  be  obtained,  or  even  a  cure  may 
result,  by  removing  the  secretions  from  the  tympanum  through  the 
Eustachian  tube,  a  successful  case  of  which,  previously  reported,*  is 
given  herewith. 

Case  3. — The  case  was  that  of  Prof.  J.  C,  Bryant,  who  at  the  time 
was  much  run  down  with  overwork.  He  had  contracted  a  severe 
head  cold  and  was  taken  with  consecutive  acute  otitis  media  on 
January  29th,  1884.  Both  ears  were  affected  in  the  beginning,  there 
being  present  much  tinnitus  and  autophonia,  which  symptoms  in- 
creased the  following  day  to  a  very  great  extent.  There  was,  further- 
more, vertigo  with  nausea,  occasional  unsteadiness  of  gait,  and  a  very 
considerable  impairment  of  the  hearing  power.  The  phenomenon  of 
staggering  was  notable,  the  patient  experiencing  concussion  of  the 
brain  and  confusion  of  ideas  from  the  sound  of  his  own  voice.  On 
the  31st  inst.  the  trouble  began  to  concentrate,  as  it  seemed,  in  the 
right  ear,  which  was  now  the  seat  of  so  much  pain  that  he  came  to 
consult  the  writer  about  it. 

Appearance  of  the  ears. — The  left  membrana  tympani  was  slightly 
hyperaemic  about  the  short  process  of  the  malleus,  but  was  otherwise 
free  from  inflammation.  The  right  membrane  had  the  general  ap- 
pearance of  being  intensely  inflamed,  but  on  close  inspection  the  in- 
flammation was  found  to  be  confined  to  the  membrana  flaccida  for  the 
most  part ;  indeed,  the  posterior  part  of  this  structure  was  greatly 
distended,'  and  was  bulging  out  as  though  it  would  burst.  The  con- 
tiguous dermic  layer  lining  the  superior-posterior  wall  of  the  canal 
was,  for  the  distance  of  some  lines,  elevated  and  very  red.  The  in- 
tumescence also  extended  somewhat  downwards  along  the  posterior 
margin  of  the  membrana  tympani,  being  sharply  limited  anteriorly  at 
the  malleus  handle.  The  swollen  membrana  flaccida  overhung  the 
comparatively  unaffected  inferior  segment  of  the  membrana  tympani, 
thus  giving  the  appearance  of  much  more  general  distention  than  ac- 
tually existed.*  This  case,  it  will  thus  be  seen,  was  one  of  acute 
catarrhal  inflammation  of  the  attic. 

'  The  Lancet,  October  18th,  1884. 

'^  The  overhanging  intumescence  above  alluded  to,' and  entirely  concealing 
the  rest  of  the  membrane  in  certain  cases,  is  most  puzzling  to  the  observer 
when  the  true  nature  of  the  disease  is  not  recognized,  and  it  is  in  such  cases 
that  disappointment  is  liable  to  be  experienced  in  consequence  of  the  escape 


OTITIS   MEDIA    ACUTA.  239 

On  being  asked  by  the  patient  who  was  seeking  relief,  if  the 
confined  secretions  might  not  be  drawn  out  through  the  Eusta- 
chian tube,  it  occurred  to  the  writer  that  the  operation  could  be 
successfully  performed  by  means  of  the  flexible  Eustachian  catheter' 
which  he  introduced  some  years  ago.  A  catheter  of  one-fourth  of  an 
"inch  in  diameter  was  introduced  through  the  inferior  nasal  passage, 
and,  after  connecting  it  with  a  large  metallic  ear  syringe  by  means  of 
a  stout  piece  of  soft  rubber  tubing  ten  inches  in  length,  suction  was 
effectually  established  by  using  the  syringe  as  in  aspiration.  It  was 
worked  by  one  hand  whilst  the  other  hand  kept  the  catheter  in  place. 
By  means  of  an  otoscopic  tube,  the  suction  in  the  affected  ear  could 
be  plainly  heard  by  the  author  with  each  pumping  stroke  of  the  pis- 
ton, the  action  being  yet  more  plainly  manifest  to  the  patient,  who, 
after  one  or  two  successful  exhaustive  efforts  had  been  made,  exclaimed, 
"  That  does  the  work  ;  the  pain  has  gone.^'  Suction  was  then  main- 
tained until  half  a  dozen  strokes  of  the  piston  were  made.  Relief 
from  the  disagreeable  tension  and  other  symptoms  was  not  only  imme- 
diate but  also  permanent,  although  the  deafness,  autophonia,  etc., 
did  not  disappear  entirely  for  some  days.  Examination  showed  the 
bulging  and  congestion  of  the  membrana  flaccida  much  reduced  and 
diminished. 

In  the  previous  attacks  of  acute  inflammation  of  the  middle  ear,  to 
which  the  same  gentleman  had  been  subject,  purulency  had  frequently 
occurred,  the  drum-heads  rupturing  spontaneously  or  being  punc- 
tured. Suppurative  action  was  probably  prevented  in  the  present  in- 
stance by  the  timely  withdrawal  of  the  secretions  from  the  tympanum. 
Under  an  after-treatment  consisting  of  small  doses  of  calx  sulphurata, 
aconite,  and  belladonna,  the  recovery  was  uninterrupted  and  com- 
plete. 

For  slight  redness  of  the  membrana  flaccida,  in  the  regressive  course, 
local  treatment  is  inadvisable.  Where  there  is  periostitis  of  the 
canal,  incisions  often  do  harm,  but  when  secretions  in  the  drum  ac- 
cumulate, the  symptoms  may  become  urgent  and  the  employment  of 
the  knife  demanded.  Vent  to  secretions  in  the  attic  may  generally 
be  assured  by  introducing  the  myringotome,  or  better  the  knife  de- 
scribed and  figured  in  Chapter  XIII.,  through  the  upper  edge  of  the 

of  air  only  when  the  membrana  tympani  is  punctured,  the  pent-up  eecretions 
being  confined  to  the  upper  chamber. 

'  This  catheter,  it  may  be  well  to  state  here,  is  made  of  flexible  rubber,  but 
is  suflBciently  unyielding  to  retain  its  shape  while  in  use.  It  has  a  soft,  vel- 
vety finish,  and  its  introduction  in  the  adult  creates  so  little  discomfort  that 
one  which  is  one-fourth  of  an  inch  in  diameter  can  generally  be  employed. 
This  is  readily  introduced  into  the  mouth  of  the  Eustachian  tube,  and  permits 
a  large  current  of  air  to  pass. 

Vide  Trans.  Am.  Otological  Society,  1881.  The  catheters  are  made  by  Mr. 
Ford,  of  Hazard,  Hazard  &  Co. 


240  OTITIS    MEDIA    ACUTA. 

membrana  tympani  and  behind  the  long  process  of  the  incus.  Since 
there  is  some  danger  of  wounding  the  chorda  tympani  nerve  in  this 
operation,  the  surgeon  should  not  carry  the  point  of  the  knife  too 
high  up, 

No  plan  of  treatment  would  be  satisfactory  where  the  mouth  or 
upper  pharynx  was  neglected. 

Under  treatment,  the  worst  agonies  of  acute  otitis  media  may  be 
prevented,  and  very  often  our  remedies  act  like  a  charm;  but  it  must 
not  be  forgotten  that  the  causes  in  a  given  case  may  not  be  so  easily 
eradicated,  and  that  treatment  must  be  kept  up  for  some  time  if  we 
would  entirely  prevent  a  return  of  this  tormenting  disease. 

The  advantages  of  rest,  both  mental  and  physical,  keeping  the  head 
in  repose,  in  acute  inflammation  of  the  middle  ear,  should  never  be 
lost  sight  of,  and  the  patient  should  be  kept  indoors  for  several  days. 
If  the  case  be  a  severe  one,  he  will  be  better  off  in  bed  for  a  time. 
Quiet  ought  to  be  maintained  in  all  cases,  for  noises  under  these 
circumstances  are  sometimes  exceedingly  distressing.  The  application 
of  moderate  dry  heat  for  pain,  when  grateful  to  the  patient,  is  advis- 
able. Much  relief  does  not  follow  the  instillation  of  anodynes,  which 
only  come  in  contact  with  the  dermic  surface;  we  are  thus  unable  to 
avail  ourselves  of  cocaine,  and  the  like,  in  these  cases.  Dry  air  or 
vapor  blown  into  the  ear  often  gives  relief,  however;  the  employment 
of  the  vapor  of  chloroform  sometimes  relieves  an  earache  in  the  man- 
ner, but,  as  with  cocaine,  its  action  when  applied  to  dermic  tissues  is 
slight. 

Of  course,  a  rigid  dietary  should  be  enforced,  and  personal  and 
general  hygiene  attended  to,  especially  in  respect  to  overheating. 
The  evils  of  active  treatment  in  these  cases,  by  syringing,  etc.,  should 
be  borne  in  mind,  and  it  may  be  here  urged  that  deafness  as  a  symp- 
tom should  not  be  treated. 

Should  inflation  of  the  tympanum,  either  by  the  air-bag  or  by  the 
Valsalvan  method,  be  now  accomplished,  the  forcible  entrance  of  air 
may  not  be  only  painful,  but  also  harmful.  These  procedures,  often 
employed  to  improve  the  hearing  in  chronic  cases,  are  of  doubtful 
value  in  acute  inflammation  of  the  middle  ear.  At  a  later  stage  of 
the  attack,  we  may,  of  course,  avail  ourselves  of  these  pneumatic 
methods. 

The  possible  relief  attained  from  the  depletion,  due  to  the  applica- 
tion of  Ifeeches,  may  be  more  than  counterbalanced  by  the  irritation 
of  their  sharp  bite  and  the  bungling  attempts  made  in  stopping  the 
bleeding  after  they  drop  off;  the  large  coagula  entangled  in  pellets  of 
cotton-wool,  used  to  arrest  hemorrhage,  are  also  liable  to  irritate  the 


OTITIS   MEDIA   ACUTA.  241 

parts,  especially  in  children.  Blistering  and  painting  with  the  tinc- 
ture of  iodine  over  the  mastoid,  or  in  front  of  the  ear,  are  generally 
useless  procedures,  and  are  not  always  harmless. 

The  well-known  tendency  of  some  drugs  to  cause  or  increase  existing 
aural  symptoms  should  warn  us  to  beware  of  their  indiscriminate  use. 
First  among  these  is  quinine,  long  suspected  of  causing  deafness 
when  administered  in  large  doses.  The  intense  tinnitus  aurium  fol- 
lowing its  administration  is  significant.  The  employment  of  ferru- 
ginous preparations  seems,  in  some  cases,  to  have  a  like  effect, 
and,  doubtless,  there  are  many  others  which  it  were  best  to  omit  when 
the  ear  is  acutely  inflamed.  During  the  existence  of  acute  aural  dis- 
ease, the  consequences  of  its  early  management  upon  the  subsequent 
course  and  duration  should  be  kept  in  mind. 

The  following  cases,  selected  from  the  records  of  a  large  number 
treated,  are  given  as  typical  examples  of  the  tendency  of  the  inflam- 
matory process,  in  many  instances,  to  stop  short  of  perforation  of  the 
drum-head;  they  illustrate,  furthermore,  the  good  results  attained  by 
a  non-meddlesome  course  of  treatment. 

Case  4, — Inflammation  of  the  atticus  tympanicus  ;  symptoms  due 
to  hloioing  the  nose.  Catarrh  of  the  upper  air-tract.  Decayed  teeth 
giving  rise  to  reflected  neuralgia.     Recovery  in  three  days. 

Patient,  male,  aged  53,  tailor;  "has  head  catarrh  and  is  deaf  in 
both  ears."  He  has  had  frequent  attacks  of  ear  catarrh  with  pain. 
After  blowing  his  nose  forcibly  yesterday  he  experienced  sudden  pain 
in  the  right  ear,  followed  by  tinnitus  and  some  increased  hardness  of 
bearing.  He  slept  well,  however,  and  there  has  been  no  discharge 
from  the  ear.  On  examination  of  right  ear,  the  membrana  flaccida, 
posterior  fold,  and  parts  about  short  process  are  found  hyperaemic. 
A  number  of  vessels  of  the  manubrial  plexus  are  injected,  their  course 
being  traced  by  delicate,  fine  thread-like  lines,  giving  the  whole  an 
arborescent  appearance.  The  membrana  tympani  of  the  left  ear  is 
lustreless,  humid,  and  somewhat  retracted,  with  marked  opacity  in 
the  posterior-inferior  segment.  Patient  hears  ordinary  voice  only  in 
both  ears.  There  is  catarrh  of  the  upper  air-passages.  The  teeth  are 
in  a  carious  condition,  a  few  old  shells  remaining. 

Aconite  and  belladonna  were  administered  in  small  doses,  repeated 
often.  Patient  next  se6n  three  days  later,  when  it  was  found  that  the 
vascularity  had  subsided,  as  had  also  the  subjective  symptoms. 

Case  ^.— Acute  inflammation  of  the  atticus  tympanicus  and  atrium 
after  sea-hathing .     Recovery  in  six  days. 

Male,  aged  15.  There  is  no  history  of  previous  ear  trouble.  Patient 
went  in  bathing  twenty-four  hours  ago,  diving  frequently.  He  does 
not  remember  having  snuffed  up  any  water  into  his  nose  or  mouth. 
A  few  hours  afterwards  he  was  seized  with  tinnitus  and  pain  in  the 
left  ear,  the  latter  being  so  severe  as  to  entirely  prevent  sleep.  There 
16 


242  OTITIS   MEDIA   ACUTA. 

were  also  autophonous  phenomena  present,  but  no  discharge.  On 
examination  of  left  ear,  the  membrana  flaccida  is  found  fleshy  in 
appearance,  partially  detaclied,  and  bulging  considerably.  The  mem- 
brana vibrans  is  uniformly  hyperasmic  and  denuded,  the  surface 
being  puckered  and  swollen.  The  right  ear  is  unaffected.  Hear- 
ing in  right  ear,  normal;  in  left,  ordinary  voice  only  is  distinguished. 
Patient  was  treated  with  calx  sulph.,  gr.  -^-^  every  two  hours, 
aconite  and  belladonna  being  given  for  the  pain.  The  following  day 
patient  returned,  stating  that  after  taking  three  doses  of  the  aconite 
and  belladonna  the  pain  had  subsided,  and  that  he  had  slept  well  for 
the  first  time  in  forty-eight  hours.  The  membrana  tympani  presents 
no  change  in  its  condition.  During  the  following  forty-eight  hours 
patient  had  some  pain  in  the  daytime,  but  rested  well  at  night  after 
taking  a  tew  doses  of  the  aconite  and  belladonna.  On  the  sixth  day, 
the  membrana  vibrans  and  membrana  flaccida  were  found,  on  exami- 
nation, to  be  clearing  up.  The  pain  had  subsided,  and  patient 
experienced  no  further  trouble. 

Case  6. — Acute  inflammation  of  atrium.  Catarrh  of  upper  air- 
tract.     Decayed  teeth.     Spontaneous  recovery. 

Female,  aged  10.  Patient  has  long  suffered  from  frequent  attacks 
of  otalgia  in  the  right  ear,  not  accompanied  by  tinnitus,  deafness,  or 
discharge.  After  *' taking  cold"  one  week  since,  severe  pain  and 
tinnitus  appeared  in  the  right  ear,  continuing  without  intermission 
until  the  present  time,  and  preventing  sleep.  Ko  discharge,  however, 
was  noticed.  On  examination  of  right  ear,  the  membrana  tympani  is 
found  desquamating,  bulging,  and  the  landmarks  are  not  visible. 
There  is  a  crust  of  exfoliated  epithelium  lying  in  front  of  the  drum- 
head. The  membrana  tympani  of  the  left  ear  is  somewhat  clouded  in 
its  posterior  segment,  the  anterior  segment  being  brilliant  in  appear- 
ance. Hearing,  right  ear,  loud  voice;  left  ear,  low  voice;  at  ten  feet 
distance. 

The  posterior  wall  of  the  pharynx  is  covered  with  adenoid  vegeta- 
tions, and  the  tonsils  are  hypertrophied.  Several  shells  of  carious 
teeth  retained  in  the  upper  and  lower  jaws,  and  an  abundant  accumu- 
lation of  tartar,  causing  reflex  irritation  in  the  ear,  would  seem  to 
account  for  the  tendency  to  recurrent  attacks  of  aural  catarrh.  She 
had  the  carious  teeth  removed.  Four  days  later,  when  again  seen, 
the  exacerbation  had  subsided  without  having  taken  any  medicine. 

Case  7. — Acute  inflammation  of  the  atrium  after  sea-bathing.  Exu- 
dation cyst  of  the  drum-head.  Chronic  catarrh  of  the  upper  air-tract. 
Cured  in  seven  days. 

Male,  aged  17,  epileptic.  Patient  is  subject  to  frequent  attacks  of 
toothache  and  pain  in  the  ears.  Bathes  very  frequently  in  summer, 
and  indulges  a  good  deal  in  diving  and  sporting  in  the  water  of  the 
sea.  During  his  last  bath,  two  and  a  half  weeks  before  coming,  he 
got  "  water  in  his  right  ear,  and  has  not  been  able  to  get  it  out "  (by 
the  usual  method  of  hopping  on  one  foot).  There  has  been  some  tin- 
nitus aurium  and  sensations  of  "  gurgling,  snapping,  ajid  sounds  of 


OTITIS   MEDIA   ACUTA.  243 

bubbles  "  in  the  ear.     No  autophonous  voice,  deafness,  or  discharge. 
During  past  twenty-four  hours,  some  pain  in  right  ear. 

Examination  of  right  ear.  A  hirge,  oval,  cyst-like  swelling  occu- 
pies the  whole  of  the  posterior  segment  of  the  membrana  tympani. 
The  surface  has  a  dermic,  lustrous  appearance.  Only  a  portion  of 
the  anterior  quadrant  can  be  seen.  Left  ear  normal.  Hearing,  low- 
voice  in  both  ears. 

In  twenty-four  hours  pain  subsided  under  the  administration  of 
aconite  and  belladonna.  As  the  symptoms  were  not  of  an  aggravated 
type,uind  as  the  cyst  was  not  increasing  in  size,  incision  was  delayed. 
On  examination,  forty-eight  hours  afterwards,  the  vesicle  on  the- 
drum-head  had  disappeared,  leaving  the  dermic  tissue  of  the  latter 
puckered  in  appearance.  Aconite  and  belladonna  discontinued.  On 
the  seventh  day  the  subjective  symptoms  had  subsided;  the  drum-- 
head  was  seen  on  examination  to  be  resuming  its  normal  appearance^ 
Patient  discharged  cured. 

Case  8. — Acute  inflammation  of  atrium  and  attic.  Odontalgia. 
Recovery  in  ten  days. 

Female,  aged  40.  No  previous  ear  trouble.  Two  weeks  ago,  after 
exposure  and  wetting  of  feet,  contracted  an  acute  catarrh  of  the 
upper  air-passages.  In  forty-eight  hours  was  taken  with  pain  in 
right  ear  accompanied  by  deafness  and  autophonia.  The  pain  has 
increased  in  severity,  and  is  aggravated  by  coughing,  sneezing,  and 
by  exposure  of  person  to  cold  air.  During  the  past  week  all  the 
teeth  in  both  upper  and  lower  jaws,  right  side,  have  been  painful. 
Patient  has  noticed  no  discharge.     General  malaise  and  anorexia. 

Examination  of  right  ear  shows  the  drum-head  and  adjacent  walls 
of  canal  to  be  denuded  and  intensely  injected.  The  flaccid  mem- 
brane is  bulging  slightly.  Landmarks  not  seen.  No  perforation  de- 
tected. The  left  drum-head  shows  evidence  of  trophic  changes. 
Hears  loud  voice  in  right  ear,  low  voice  in  left.  Pharynx  is  con- 
gested. Right  lower  sixth  year  molar  is  pulpless,  and  there  is 
inflammation  of  the  gums  and  accumulations  of  tartar  on  the  teeth. 

Patient  was  given  calx  snlph.  (gr.  -^  every  three  hours),  and 
was  sent  to  dentist  to  have  molar  tooth  extracted.  In  twenty-four 
hours  there  was  decided  amelioration  of  pain.  The  inflamed  parts, 
however,  were  still  hyperaemic,  and  the  bulging  of  flaccid  membrane 
had  not  increased.  During  the  next  six  days,  there  was  gradual  sub- 
sidence of  subjective  symptoms,  and  treatment  was  discontinued  on 
the  seventh  day.  On  the  tenth  day  after  admission,  the  drum-head 
was  clearing  up,  low  voice  was  heard  in  the  affected  ear,  and  patient 
had  no  further  trouble. 

Case  9. — Acute  inflammation  of  attic  and  congestion  of  mem- 
Irana  flaccida.     Atrium  and  membrana  vihrans  not  itivolved. 

Male,  aged  23.  Three  years  ago  had  earache  in  right  ear,  with- 
out discharge.  "  Takes  cold  easily.^'  Three  days  ago  was  taken 
with  pain  in  the  left  ear,  aggravated  by  coughing,  mastication,  sneez- 
ing, etc.,  and  by  pulling  on  the  auricle.  He  has  noticed  autophonia 
and  deafness,  but  no  discharge.     Sleeps  well. 


244  OTITIS    MEDIA    ACUTA. 

Examination  of  the  left  ear  shows  the  membrana  fiaccida  and  su- 
perior adjacent  wall  of  canal  to  be  injected;  the  membrana  vibrans  is 
normal  in  appearance.  Some  ten  minutes  after  first  examination,  a 
second  examination  was  made  (the  patient  having  complained  of 
more  pain),  when  a  very  marked  increase  in  the  intensity  of  the  con- 
gestion was  observed.  The  right  ear  was  normal.  Patient  heard  low 
voice  in  the  left  ear,  lowest  voice  in  the  right.  Calx  sulpli.  (-gV  of 
a  grain)  administered  every  two  hours,  and  aconite  and  belladonna 
every  fifteen  minutes,  resulted  in  relief. 

Of  course,  the  experienced  observer  will  nearly  always  be  able  to 
Judge  from  the  constitution  of  the  patient,  and  the  progress  the  dis- 
ease has  already  made,  as  to  its  probable  severity.  Some  of  the  cases 
above  reported  very  well  illustrate  the  effects  of  the  rapid  effusion 
which  sometimes  takes  place  in  the  attic,  especially  in  the  early  stage 
of  inflammation,  in  consequence  of  which  there  is  detachment  of  the 
dermic  layer  of  both  drum-hestd  and  canal  walls  immediately  in  front 
of  this  region,  with  more  or  less  tumefaction.  The  early  recognition 
■of  acute  otitis  media  is  important,  especially  where  the  attic  is  chiefly 
involved. 

These  cases  are  noteworthy  on  account  of  the  absence  of  perfora- 
tions in  the  drum-head,  and  consequently  of  otorrhoea.  The  vibrating 
portion  of  the  drum-head  being  unaffected,  there  was  but  little  deaf- 
ness, and  there  was  no  autophonia.  In  a  certain  number  of  these 
cases,  there  would  doubtless  have  been  a  rupture  of  the  drum-head  but 
for  the  escape  of  fluids  via  the  Eustachian  tube.  The  exudation  cyst 
described  in  Case  7  was  not  large  and  did  not,  therefore,  prevent 
a  diagnosis  being  readily  made  ;  when  these  cyts  are  large,  involving 
the  greater  portion  of  the  drum-head,  the  appearances  are  mislead- 
ing, even  to  an  expert,  since  all  of  the  natural  landmarks  are  oblit- 
erated. It  will  be  observed  that  in  Case  9  the  careful  introduction 
of  a  speculum  for  the  inspection  of  the  deeper  parts  was  followed  by 
an  increase  of  hyperaemia  and  pain;  attempts  at  establishing  a  com- 
plete diagnosis  by  prolonged  examination,  and  the  thorough  removal 
of  epithelial  products  and  the  like  from  the  ear,  are  therefore  often 
inadvisable,  since  these  procedures  are  liable  to  injure  the  inflamed 
parts. 

Too  much  stress  cannot  be  laid  on  the  advantages  of  letting  well 
alone,  persevering  and  fussy  local  manipulations  nearly  always  doing 
harm. 


OTITIS   MEDIA   8UBACUTA.  245 


OTITIS  MEDIA   SUBACUTA. 

This  is  often  a  sequence  of  otitis  media  acuta,  but  in  a  consider- 
able number  of  subjects  seen  by  the  writer  the  trouble  seemed  to 
have  begun  as  a  subacute  process.  In  many  instances,  however,  it 
appeared  in  cases  affected  with  chronic  inflammation  of  the  middle 
ear.  We  find  it  occasionally  arising  in  an  organ  in  which  the  results 
of  chronic  purulent  inflammation  remain,  such  as  thickening,  adhe- 
sions, opacities,  perforations,  and  the  like.  It  may  result  from  sniff- 
ing up  solutions  of  various  kinds,  the  use  of  irritating  snuff,  sea 
bathing,  the  presence  of  foreign  bodies,  and  the  like. 

In  84  cases  taken  from  the  author's  records,  55  were  males  and  29 
females.     Their  ages  were  as  follows: 

Between    land    3  years 5  cases. 

3andll      "     15  " 

11  and  21     "     16  " 

21and31      '«     22  " 

"       31  and  41     "     14  " 

41and51     "     8  " 

51  and  61      "     2  " 

Over  61  years 2  " 

Total 84      " 

In  31  of  these,  severe  head  colds,  ozaena,  rhinitis,  and  naso-pharyn- 
geal  affections  generally  were  noted  as  prominent  causative  influ- 
ences. In  45  of  the  cases,  dentition  in  some  stage,  caries  of  the  teeth, 
and  other  oral  irritation,  was  present.  The  presence  of  a  wisdom 
tooth  erupting  with  difficulty,  or  a  tooth  on  the  same  side  filled  after 
destruction  of  the  pulp,  was  seen  in  several  instances  to  keep  up  the 
aural  trouble.  Subacute  inflammation  was  observed  to  be  a  sequence 
of  measles,  pertussis,  and  syphilis  in  a  number  of  instances;  and  in 
one  case  exposure  to  compressed  air  in  a  caisson  of  the  Hudson  River 
Tunnel.  Eczema  and  a  rheumic  diathesis  existed  in  several  instances, 
standing  in  a  causative  relation  to  the  trouble. 

In  a  few  cases  the  process  began  in  the  attic,  and  in  several  there 
was  hyperaemia  or  dermatitis  of  the  adjacent  walls  of  the  external 
auditory  canal. 

Objective  Symptoms.  The  appearances  of  the  drum-head  were  always 
characteristic,  the  same  being  red  and  dry.  This  dry  appear- 
ance is  a  very,  if  not  the  most,  prominent  feature  of  the  tympanic 
membrane  in  chronic  subacute  otitis  media;  in  one  case  only  was  a 
decided  collection  of  secretions  in  the  drum  noted. 


246  OTIXJS   MEDIA   STJB ACUTA. 

In  a  large  number  of  instances,  the  drum-head  was  greatly  re- 
tracted, being  sometimes  indistinguishable  from  the  inner  wall  of  the 
canal  but  for. the  prominence  of  the  short  process;  when  thickening 
of  the  parts  about  the  upper  segment  was  great,  even  this  could  not 
be  well  seen.  The  drum-head  remains  intensely  red  in  some  cases  for 
an  almost  indefinite  period,  owing  to  the  persistency  of  exciting 
causes,  or  frequent  recurrences  of  head  colds;  this  is  especially  the 
case  with  children. 

Subjective  Symptoms  andr  Course.  In  a  number  of  cases,  distress- 
ing noises  in  the  ears  were  noted,  and  likewise  autophonia,  causing 
even  greater  discomfort.  Symptoms  of  vertigo  were  marked  in  some 
cases,  and  in  quite  a  number  there  was  extreme  nervousness  and 
neurasthenia.  One  person  was  the  subject  of  delusions  and  other 
alarming  phenomena.  Deafness  was  extreme  in  nine* cases,  three  of 
whom  were  totally  deaf,  the  origin  of  which  was  claimed  to  have  been 
meningitis.  In  four  individuals,  the  development  of  the  trouble  had 
been  rapid,  the  accompanying  deafness  sudden  and  great. 

In  but  one  of  the  author's  cases  was  the  hearing  unaffected.  Head- 
ache, neuralgia  about  the  ear,  otalgia  sometimes  lasting  for  weeks, 
and  other  nervous  phenomena  were  observed  to  a  greater  or  less  de- 
gree in  a  very  considerable  number.  Deafness  was,  however,  the 
most  frequent  cause  of  complaint,  school  children  being  brought 
especially  on  account  of  this  symptom. 

The  course  of  subacute  inflammation  tends  decidedly  toward  chro- 
nicity;  it  may  continue  for  months  or  years.  On  the  other  hand,  how- 
ever, it  may  be  kindled  up  into  an  acute  purulent  process.  The 
retraction  of  the  drum-head  is  probably  due,  in  the  greater  number  of 
cases,  to  closure  of  the  Eustachian  tube,  either  at  its  pharyngeal  or 
tympanic  orifice. 

These  cases  of  subacute  otitis  media  are  often  quite  intractable, 
owing  to  the  unfavorable  condition  of  the  patient  as  regards  suscep- 
tibility to  colds  and  dental  irritation. 

Prognosis.  Under  these  circumstances,  the  prognosis  not  always 
favorable,  since  the  hygienic  conditions  are  beyond  the  physician's  con- 
trol, and,  moreover,  the  deformity  of  the  transmitting  mechanism,  due 
to  great  retraction  of  the  drum-head  in  protracted  cases,  becomes  finally 
irremediable. 

Treatment.  As  regards  prophylaxis  and  hygiene,  the  treatment  is 
similar  to  that  mentioned  in  the  management  of  acute  inflammation 
of  the  middle  ear.  Inflation  of  the  drum  by  Politzer's  method  is 
advantageous  and  may  be  practised  daily  for  a  time;  on  improvement 
taking  place,  however,  it  should  be  done  less  frequently:     In  adults 


OTITIS   MEDIA    SEROSA.  24'? 

the  ear  may  be  inflated  to  advantage  in  some  instances  by  means  of 
the  Eustachian  catheter. 


OTITIS  MEDIA  SEROSA. 

So  far  as  is  known  to  the  writer,  this  form  of  middle  ear  disease  is 
not  mentioned  in  the  older  works  on  the  ear ;  later  writers,  however, 
such  as  Burnett,  Barr,  Schwartze,  and  others  have  described  it. 

The  pathogenesis  and  etiology  of  the  serous  form  of  middle  ear  in- 
flammation is  similar  in  many  respects  to  that  of  subacute  inflamma- 
tion of  this  region.  It  arises,  however,  nearly  always  in  subjects  hav- 
ing a  well  pronounced  rheumatic  or  gouty  diathesis.  The  occurrence 
of  this  trouble  is  doubtless  much  more  frequent  than  the  small 
number  of  cases  seen  by  the  writer  would  seem  to  indicate,  since  in 
all  of  these  the  external  auditory  canal  was  unusually  large,  affording 
a  good  view  of  the  fundus.  It  is,  therefore,  probable,  that  many 
cases  escape  observation  where  the  canal  is  small. 

This  affection  is  essentially  one  of  advanced  life ;  the  author  at 
least  has  never  seen  a  case  in  childhood.  Of  twenty-five  cases  of 
which  notes  were  taken,  sixteen  were  males  and  nine  females.  The 
youngest  patient  was  fifteen  years  of  age,  the  oldest  sixty-seven. 
Nine  were  between  twenty  and  thirty,  eight  between  thirty  and  forty, 
six  between  forty  and  fifty  years  of  age. 

Objective  Sy^nptoms.  The  drum-head  may  or  may  not  be  much  in- 
flamed. In  several  instances  where  the  attack  followed  the  entrance 
of  sea  water  in  bathing,  there  was,  at  first,  considerable  myringitis 
present ;  and  where  the  trouble  first  manifested  itself  principally 
in  the  attic,  there  was  some  tendency  to  the  formation  of  an  abscess 
from  the  burrowing  of  fluids  along  the  upper  and  posterior  walls  of 
the  canal.  The  canal  is  sometimes  hyperaemic  at  its  inner  extremity; 
in  one  case  seen,  there  was  a  desquamative  process  going  on.  Gene- 
rally, however,  the  drum-head  was  found  relaxed  and  more  or  less 
macerated  in  appearance,  with  sufficient  translucency  to  admit  of  the 
serdus  contents  of  the  drum  being  seen.  The  collection  of  fluid, 
being  for  the  most  part  confined  to  the  atrium,  is  easily  seen.  On 
first  looking  into  the  ear,  the  observer  is  liable  to  mistake  the  surface 
line  of  the  fluid  contained  in  the  drum  for  a  hair  lying  horizon- 
tally across  the  drum-head  ;  the  writer  well  recalls  how  he  was  first 
misled  in  this  manner.  The  Valsalvan  experiment  affords  an  instruc- 
tive picture  of  the  fundus ;  the  air  thus  forced  into  the  drum  fills 
the  cavity  more  or  less  with  bubbles  which  range  themselves  on  the 
inner  surface  of  the  drum-head  and  are  thus  plainly  visible.     The 


24S  OTITIS   MEDIA   SEROSA. 

fluid,  moreover,  alters  its  position  with  every  change  of  the  patient's 
head — the  hair-like  line  mentioned  above  showing,  of  course,  the  sur- 
face of  the  fluid.  The  drum-head,  as  just  stated,  is  nearly  always  re- 
laxed, its  loss  of  tension  being  observable  if  the  ear  be  viewed  during 
the  Valsalvan  experiment. 

Subjective  Symptoms  and  Course.  The  invasion  usually  manifests 
itself  during  a  severe  cold  in  the  head,  the  local  symptoms,  though 
sometimes  of  an  acute  nature,  never  exhibiting  a  tendency  toward 
suppuration.  In  the  greater  number  of  instances,  however,  the 
trouble  began  as  a  subacute  inflammation ;  in  two  instances,  there 
was  also  acute  myringitis  present. 

Pain  in  the  ear  is  not  usually  present,  though  in  one  case  of  the 
acute  form  it  was  severe  for  a  short  time,  whilst  in  another  instance 
it  was  decidedly  annoying.  Where  dead  teeth  were  found,  some  neur- 
algia generally  existed. 

Most  of  the  patients  were  greatly  alarmed  at  the  symptoms,  and 
came  more  on  account  of  the  autophonia,  sensation  of  "  numbness  '* 
about  the  ear,  and  nervousness,  than  in  consequence  of  pains  or  deaf- 
ness. Among  women  at  the  menopause,  the  neuropathic  condition 
was,  in  several  instances,  extreme  and  gave  rise  to  distressing  appre- 
hensions on  the  part  of  the  patients  themselves. 

Autophonia  existed  in  nearly  every  case ;  in  several  individuals 
vertigo  was  present,  "  creeping ''  sensations  in  the  ears,  etc.  One 
patient,  a  lady,  experienced,  on  stooping  over,  a  sensation  of  the 
drum-head  ''flopping  down,"  as  she  expressed  it;  on  elevating  the 
head  it  •'  went  back.'' 

The  comparatively  small  amount  of  deafness  in  these  cases  is  proba- 
bly due  to  the  slight  interference  oJBfered  by  the  serous  fluid  in  the 
drum  to  the  action  of  the  transmitting  mechanism  ;  the  modification 
of  the  drum's  resonance,  owing  to  the  pressure  of  the  fluid  and  the 
relaxed  condition  of  the  drum-head,  serves  to  explain  the  autophonous 
phenomena. 

The  course  of  this  disease  is  generally  very  slow,  continuing,  in 
most  instances,  for  weeks  and  months.  The  patient  is  liable  to  a  re- 
turn of  the  trouble  with  every  recurrence  of  head  cold ;  a  cure,  how- 
ever, may  be  promised  in  most  cases. 

Treatment.  The  treatment  should,  in  a  general  way,  be  directed 
to  the  diathetic  trouble,  and  here  we  may  avail  ourselves  of  the  expe- 
rience of  the  regular  family  medical  attendant.  Locally  the  naso- 
pharynx should  attract  our  attention,  and  an  occasional  inflation  by 
means  of  Politzer's  method  will  be  found  beneficial. 

Pressure  upon  the  drum-head  bv  the  rarefaction  of  air  in  the  exter- 


OTITIS    MEDIA    CHRONICA.  249 

nal  auditory  canal  will,  in  some  instances,  be  of  service  in  expelling 
the  fluid  via  the  Eustachian  tube.  "VVe  must,  in  these  cases,  however, 
rely  mainly  upon  absorption  ;  this  is  not  a  rapid  process  in  run-down 
persons  past  the  meridian  of  life. 


OTITIS   MEDIA   CHKONICA. 

Chronic  catarrh  of  the  middle  ear.  As  far  as  the  pathogenesis  is 
concerned,  inflammatory  affections  of  the  upper  air-tract  should  be 
considered  as  a  whole,  although  the  ear,  olfactory  region,  and,  in  a 
lesser  degree,  the  various  cavities  and  sinuses  of  the  head,  may  be- 
come specially  affected  at  times,  one  more  so  than  the  other. 

By  far  the  greater  number  of  aural  affections  coming  to  the  notice 
of  the  otologist  are  of  this  nature.  The  disorders  of  the  mucous 
membrane  of  the  middle-ear  tract  under  consideration  comprise  the 
more  or  less  protracted  vaso-motor  or  sensory  disturbances  affecting 
its  secretion  and  nutrition.  The  aural  reflex  neuroses  concerned 
may  owe  their  origin  to  nervous  irritation  propagated  from  numerous 
sources,  as  the  brain,  stomach,  naso-pharynx,  teeth,  genital  organs, 
etc.  Mental  impressions  are  well  known  to  exert  an  important  in- 
fluence on  the  secretion  of  the  upper  air-tract ;  thus  under  the  influ- 
ence of  grief  we  find,  in  persons  of  a  susceptible  nature,  that  lachrymal 
and  nasal  secretions  are  freely  poured  out,  and  that  such  persons  are 
extremely  liable  to  head  colds.  This  example  of  profuse  secretion 
serves  to  point  out  the  manner  in  which  both  secretion  and  nutrition 
may  be  influenced  by  long- continued  mental  strain  and  worry.  The 
writer  has  seen  numerous  instances  among  professional  and  business 
men  of  New  York,  where  overwork  has  been  followed  by  disease  of 
the  outer  or  middle  ear,  long  before  symptoms  of  a  general  breaking 
down  of  the  system  manifested  themselves  in  other  ways.  In  a  like 
manner,  the  ear  is  affected  by  influence  from  other  regions  of  the  body; 
these  have  been  discussed  elsewhere  (see  Causes  of  Ear  Disease, 
Part  II.  of  this  work). 

The  pathological  changes  produced  by  this  disease  are  similar  to 
those  taking  place  under  like  conditions  in  other  mucous  surfaces. 
We  shall  find  that  in  hypertrophic  inflammation  the  mucous  mem- 
brane becomes  thickened  from  the  proliferation  of  tissue  ;  the  Eu- 
stachian tubes  becoming  more  or  less  obstructed,  preventing  intra- 
tympanic  air-renewal,  as  shown  by  the  retracted  drum-head,  which, 
under  the  exterior  air-pressure,  is  kept  in  a  more  or  less  hypergemic 
condition.     This  retracted  state  of  the  drum-head  may  continue  for 


250 


OTITIS    MEDIA    CHRONICA. 


along  time,  depending  somewhat  on  the  age  and  condition  of  the 
patient.  It  is  particularly  a  disease  of  childhood  and  youth.  Sooner 
or  later,  however,  under  long  continued  reflex  hyperemia,  atrophic 
changes  take  place  in  the  mucous  membrane,  and  where  the  Eusta- 
chian tubes  remain  long  closed,  the  effect  of  pressure  upon  the  exterior 
of  the  drum-head  is  shown,  especially  where  acute  or  subacute  inflam- 
mation has  intervened.  The  behavior  of  secretions  under  these 
pathological  changes  in  the  mucous  membrane  has  probably  much  to 
do  with  the  interference  in  the  movements  of  the  transmitting  mech- 
anism ;  the  character  and  quantity  of  these  secretions  is  modified  by 
the  nature  of  the  inflammation,  being  mucous,  serous,  etc. 

Etiology.  An  analysis  of  1,791  cases  of  chronic  otitis  media,  of 
which  the  author  kept  notes,  gives  some  points  of  interest  in  this 
connection.     The  ages  and  sex  of  these  patients  were  as  follows: 


AOE. 

Under  5  years 

Between  5  and  10  vears 
Between  10  and  20  '  " 
Between  20  and  bO  " 
Between  30  and  40  " 
Between  40  and  50  " 
Over  50  years 

Total 


Males. 

Females. 

17 

8 

52 

44 

137 

146 

253 

222 

200 

152 

157 

126 

182 

116 

977 

814 

Total. 

25 
76 

283 
474 
352 
283 
298 

1,791 


In  a  considerable  number,  where  it  was  claimed  that  an  hereditary 
tendency  existed,  it  was  found  that  a  number  of  persons  in  the  same 
family  were,  from  similarity  of  constitution  and  manner  of  living, 
specially  susceptible  to  causative  influences.  There  were  over  100 
cases  where  an  aggravation  of  the  trouble  could  be  traced  directly  to 
syphilitic  infection,  and  it  seems  probable  that  in  many  others  where 
syphilis  was  denied,  or  the  patients  were  ignorant  of  its  existence  in 
themselves  or  parents,  its  influence  on  general  health  was  felt. 
In  31  cases,  decidedly  intemperate  habits  were  noted,  and  in  a  con- 
siderable number  this  and  dissolute  living,  etc.,  undoubtedly  induced 
or  greatly  exaggerated  the  condition  of  the  organ  and  consequent 
deafness  and  other  symptoms.  In  114  of  the  female  patients,  irregu- 
lar menses,  pregnancy,  childbirth,  uterine  troubles,  etc.,  seemed  to 
exeVcise  a  decidedly  untoward  influence. 

Of  these  cases,  74  were  at  the  same  time  afEected  in  one  ear  with 
acute  purulent  inflammation,  and  112  with  chronic  purulent  inflam- 
mation of  the  middle  ear.  In  221  cases  there  was  impacted  cerumen, 
and  in  15  cases  seborrhcea. 


OTITIS    MEDIA    CHRONICA.  *251 

There  was  marked  inflammation  of  tlie  upper  air-passages,  includ- 
ing cases  of  hypertrophied  tonsils  in  900  cases.  Oral  irritation  due 
to  caries,  eruiJtion  of  teetli,  etc.,  was  present  in  882  cases,  and  in  116 
cases  of  these  latter,  vulcanite  and  other  ill-fitting  and  unhealthful 
dental  plates  were  found  to  be  worn. 

The  size  and  curvature  of  the  external  auditory  canals,  in  numerous 
instances,  showed  great  variations;  in  312  cases  they  were  unusually 
large,  some  of  them  being  of  enormous  size.  In  a  few  instances  the 
canals  were  very  small.  From  such  facts  the  inference  might  be 
drawn  that  in  some  way  persons  with  unusually  large  canal^  are 
more  susceptible  to  certain  causative  influences.  In  448  cases  de- 
generative changes  were  found  in  the  drum-head,  whilst  in  99  in- 
stances a  marked  deformity  gave  evidence  of  imperfect  development. 

In  advanced  life,  and  often  at  an  earlier  period,  where  a  general 
breaking  down  of  the  system  is  manifest,  we  sometimes  discover  such 
a  state  of  things  in  the  defective  condition  of  the  drum  of  the  ear 
and  its  mechanism  before  other  symptoms  attract  special  attention, 
since  there  are  generally  very  distressing  aural  symptoms,  as  noises 
in  the  head  or  ear,  autophonia,  deafness,  and  sometimes  vertigo.  In 
consumptives  and  subjects  of  albuminuria  or  diabetes  mellitus,  a  re- 
laxed drum-head  and  tendency  to  serous  or  suppurative  action  mani- 
fest themselves  for  a  long  time  before  assuming  an  active  form. 

Objective  Symjjtoms.  The  appearances  of  the  drum-head  in  this 
disease  are  generally  characteristic;  thus,  in  some  instances  it  will 
usually  be  found  more  or  less  opaque  and  thickened.  Sometimes 
opacities  in  various  forms,  sizes,  mostly  semi-lunar  in  shape,  gradu- 
ally make  their  appearace,  most  frequently  upon  the  posterior 
segment.  This  tendency  to  trophic  changes  on  the  posterior  aspect 
has  doubtless  some  significance;  it  indicates  probably  the  greater 
influence  of  the  nervous  supply  of  this  region.  Very  often  the  entire 
drum-head  presents  a  uniform,  porcelain-like,  whitish  appearance, 
the  surface  having  a  dry,  glazed  look. 

In  other  instances  the  membrane  assumes  a  thin,  often  humid 
and  translucent  appearance  at  first,  which  in  many  cases  then  gradu- 
ally changes  to  a  dry,  parchment-like  condition.  Sometimes  the  dis- 
appearance of  connective  tissue  will  bring  into  view  the  radiating 
and  circular  fibres  of  the  drum-head;  and  where  acute  purulent  in- 
flammation has  intervened,  various  changes  in  the  appearance  of  the 
parts  may  be  found.  Sclerosis  of  the  membrane  is  a  sequence  of  the 
pathological  processes  described. 

In  some  cases,  however,  the  drum-head  remains  thin  and  translu- 


252  OTITIS    MEDIA    CHKOKICA. 

cent,  so  that  the  inner  wall  of  the  drum  and  the  long  process  of  the 
incus  and  the  stapes  are  plainly  visible  through  it. 

In  sclerosis  which  is  so  liable  to  be  attended  with  great  deafness,  but 
slight  changes  may  be  observed  in  the  appearance  of  the  drum-head, 
its  normal  brilliancy  remaining  almost  unchanged  in  many  cases. 

It  is  not  to  be  supposed,  however,  that  the  otologist  will  always  be 
able  to  determine  the  exact  condition  of  the  drum  from  the  appearances 
above  described  in  the  drum-head,  since  these  are  not  always  by  any 
means  well  defined,  and,  moreover,  each  variety  is  liable  to  be- 
come modified  from  various  causes,  as,  for  instance,  the  general  con- 
dition of  the  patient,  intercurrent  exacerbations  of  acute  purulent  or 
non-purulent  inflammation;  thus  the  parts  are  often  thickened  or 
marked  by  cicatricial  reproductions  either  thin  or  opaque. 

Subjective  Symptoms  and  Course.  Chronic  non-suppurative  (ca- 
tarrhal) inflammation  of  the  middle-ear  occurs  at  any  time  afterbirth, 
often  as  the  sequence  of  acute  or  subacute  inflammation  of  this  re- 
gion. Though  a  very  inconsiderable  amount  of  deafness  will  prevent 
a  child  from  learning  to  talk,  this  symptom  is  frequently  not  observed 
until  the  infant  is  several  months  old;  indeed,  the  writer  has  observed 
instances  where  one  or  two  years  had  already  elapsed  before  a  con- 
viction of  the  child's  dumbness  forced  on  the  parents  the  knowledge 
of  its  deafness.  This  subject  will,  however,  be  treated  of  elsewhere 
(Chapter  XVIII.) 

Usually  the  advance  of  the  trouble  under  consideration  is  gradual; 
its  very  existence  may  not  be  discovered  until  very  considerable  deaf- 
ness has  occurred.  Generally  the  disease  goes  gradually  on  until 
some  acute  or  subacute  exacerbation  from  *'  colds"  produces  a  rapid 
increase  of  deafness  from  pathological  changes  in  the  transmitting 
mechanism  of  the  ear.  One  ear,  usually  the  left,  is  found  to  be  first 
affected,  and  in  the  end  most  impaired. 

Exacerbations  occur  in  susceptible  persons  very  frequently  from 
exposure  to  vicissitudes  which  give  rise  to  colds.  The  occurrence  of 
*'  catarrh"  in  the  ear  alone  is  rare;  it  generally  affects  the  entire  upper 
air-tract  almost  simultaneously,  though  from  the  well-known  metas- 
tatic nature  of  mucous  membrane  inflammation  it  may  almost  entirely 
disappear  from  one  locality  of  the  general  air-tract  to  immediately 
show  itself  in  some  other.  We  must  not  suppose,  therefore,  that 
where  bronchitis  exists  one  day,  a  rhinitis  the  next,  and  an  otitis  the 
day  following,  the  inflammation  travels  along  the  mucous  tract  by 
continuity  in  all  cases. 

Deafness,  as  before  stated,  usually  comes  on  gradually,  but  acute 
or  subacute  inflammatory  exacerbations,  especially  the  latter,  causing 


OTITIS   MEDIA   CHRONICA.  253 

either  proliferation  of  connective  tissue  about  the  articular  surfaces, 
membranous  exudation,  or  the  secretion  of  tough  mucus,  greatly  in- 
crease the  defects  in  the  hearing  power. 

These  processes  are  all  of  them  often  more  or  less  sudden,  and  the 
consequent  deafness  more  or  less  permanent.  The  hearing  of  the  deaf 
is  generally  worse  after  mental  strain,  or  exhaustion  from  any 
cause;  this  is,  moreover,  retro-active,  since  the  consciousness  of  their 
own  defectiveness  in  this  respect  serves  to  increase  the  mental  depres- 
sion usually  present  among  this  class  of  patients. 

The  normal  quantity  of  mucus  secreted  in  the  drum  is  small,  and 
probably  disappears  almost  entirely  by  means  of  evaporation,  along 
with  the  air  which  ventilates  the  organ;  but  the  abnormal  secretions 
mentioned  cannot  escape  in  this  manner,  having  to  find  their  way  out 
through  the  Eustachian  tube  or  be  absorbed. 

Whilst  healthy  persons  are  less  susceptible  to,  and  quickly  recover 
from  attacks  of  acute  catarrh  of  the  middle  ear,  the  disease  is,  in  run 
down,  decrepit,  and  cachectic  subjects,  more  liable  to  go  on  to  chro- 
nicity  with  consequent  deafness. 

For  an  account  of  other  important  subjective  symptoms  occurring 
in  the  disease  under  consideration,  such  as  noises  in  the  ear,  auto- 
phonia,  aural  hallucinations,  etc.,  the  reader  is  referred  to  the  detailed 
account  of  the  anomalies  of  audition  treated  of  in  Chapter  XVI. 
Vertigo  and  various  reflex  phenomena  occur  in  the  course  of  many 
extreme  cases. 

As  regards  the  symptoms  occurring  among  the  1,791  cases  enume- 
rated above,  neuralgia  was  experienced  in  90,  distressing  noises  in  the 
ears  in  430,  autophonia  in  307,  vertigo  in  138,  and  otalgia  in  36  cases. 
Anomalies  of  audition,  such  as  dysacousma,  aural  hallucinations, 
better  hearing  in  a  noise,  etc.,  were  very  marked  in  86  cases,  though 
present  in  some  degree  in  a  much  larger  number. 

A  large  number  of  patients  gi\e  but  little  heed  to  a  moderate  amount 
of  deafness,  especially  so  long  as  the  hearing  of  one  ear  remains  fairly 
good.  Persons  are  much  more  likely  to  apply  for  relief  when  noises 
in  the  ear  exist,  or  other  subjective  symptoms  usually  accompanying 
chronic  otitis  media;  or  they  are  induced  to  seek  relief  when  their 
occupation  is  interfered  with  by  the  deafness. 

Diagnosis.  The  diagnosis  of  chronic  non-suppurative  inflammation 
of  the  middle  ear  will  not  be  difficult  from  what  has  already  been  said. 
In  cases  of  extreme  deafness,  however,  the  question  will  sometimes 
arise  as  to  whether  the  auditory  nerve  or  auditory  perception  tract  are 
involved.     This  question  has  an  important  bearing  in  the  case  of 


254:  OTITIS    MEDIA    CHRONICA. 

deaf  children,  and  has  been  discussed  in  that  connection  (Chapter 

XVIII.). 

In  the  extreme  deafness  of  chronic  inflammation  with  which  we 
have  to  deal  in  this  connection,  where,  as  a  general  thing,  the  defec- 
tiveness of  the  hearing  power  has  advanced  gradually,  the  nerve 
probably  suffers  deterioration  from  disuse  and  also  from  age;  besides, 
the  perceptive  centre  declines  in  power  along  with  other  mental  func- 
tions. So  long  as  subjective  phenomena,  such  as  noises  in  the  head, 
autophonia,  etc.,  exist,  we  may  conclude  that  nervous  sound  trans- 
mission goes  on.  When  these  are  no  longer  experienced,  and  the 
patient  cannot  hear  his  own  voice,  it  must  be  inferred  that  defective- 
ness of  the  inner  ear  exists. 

Some  writers  recommend  the  use  of  a  tuning  fork  placed,  while 
vibrating,  upon  the  teeth,  vertex,  glabella,  or  mastoid  process,  in 
order  to  determine  the  transmissibility  of  sound  irrespective  of  the 
conductive  mechanism  of  the  middle  ear;  but  the  patient's  ability  to 
estimate  the  value  of  this  experiment  varies  greatly,  and  it  is  not 
generally  so  good  a  test  as  that  of  the  vibrating  vocal  chords.  These 
latter,  namely,  produce  sounds  with  which  the  patient  is  more  familiar, 
even  if  not  so  intense  or  high  sounding  as  those  of  the  above-named 
instrument.  The  perceptive  or  auditory  region  of  the  brain,  when 
taking  cognizance  of  sound  under  diflficulties  of  both  middle  ear  and 
nervous  transmission,  cannot  always  differentiate  between  sounds 
transmitted  by  means  of  the  normal  mechanism,  though  badly,  and 
those  transmitted  through  other  media.  When  in  doubt,  the  patient 
usually  fancies  they  are  '*felt."  Hearing  in  some  very  deaf  persons, 
though  extremely  defective  in  quality,  seems  to  take  place  through 
the  tissues  of  the  head  without  the  aid  of  the  transmitting  mechanism 
of  the  middle  ear.  Thus,  it  was  found  in  a  case  of  almost  total  deaf- 
ness from  chronic  middle  ear  inflammation,  examined  by  Dr.  0.  H. 
Burnett  and  the  writer,  that  loud  voice  heard  at  a  few  inches  from 
the  ear  was  equally  distinguishable  when  both  meatus  were  completely 
closed  by  the  fingers,  the  words  being  spoken  at  the  back  of  the 
patient's  head. 

So  far  as  the  treatment  is  concerned,  in  cases  of  extreme  deafness  as 
a  result  of  chronic  inflammation,  differentiation  is  not  important, 
whilst  in  slight  cases  diagnosis  is  less  difficult. 

Prognosis.  The  prognosis  of  chronic  inflammation  of  the  middle 
ear  depends  upon  the  age,  general  health,  and  existing  degree  of  de- 
fectiveness in  the  organ.  This  latter  cannot  always  be  determined 
by  the  appearance  of  the  drum-head,  since,  in  many  cases  where  fixa- 
tion is  irremediable  by  ordinary  treatment,  but  little  change  in  the 


OTITIS   MEDIA    CHRONICA.  255 

appearance  of  the  transmitting  mechanism  is  found.  Where  great 
fixation  on  the  one  hand,  or  extensive  loss  of  tension  of  the  transmit- 
ting mechanism  on  the  other  hand  exists,  with  extreme  deafness, 
but  little  improvement  may  be  expected  from  other  than  surgical 
interference. 

In  by  far  the  greater  number  of  cases,  however,  the  progress  of  the 
inflammation  may  be  more  or  less  controlled,  provided  the  patient 
submits  to  proper  hygienic  regulations;  indeed,  in  progressive  sclero- 
sis this  is  a  sine  qua  non. 

Treatment.  For  no  other  ailment  is  relief  so  confidently  sought 
in  vain  as  chronic  catarrhal  inflammation  of  the  middle  ear;  and  in 
no  other  is  there  greater  reluctance  to  accept  the  prognosis,  so  often 
made  by  the  candid  consultant,  in  respect  to  the  irremediable  nature 
of  sclerotic  transformation  of  the  mucous  membrane,  which  has  for 
its  chief  symptoms  deafness,  autophonia,  and  noises  in  the  head. 

In  a  very  large  proportion  of  these  cases,  our  treatment  must  be 
directed  rather  to  prophylaxis  than  cure,  and,  unfortunately,  many 
persons,  whilst  greatly  concerned  about  the  ills  they  have,  are  unwill- 
ing to  take  measures  to  prevent  those  of  the  future.  The  very  first 
step,  however,  should  be  to  remove  or  diminish  exciting  causes  to  as 
great  an  extent  as  possible,  bearing  in  mind  that  certain  predisposing 
influences,  such  as  heredity  and  constitutional  taint,  are  more  or  less 
beyond  control,  and  that,  at  best,  our  efforts  may  arrest  the  progress 
of  the  trouble  only. 

Remembering  the  progress  the  disease  has  already  made,  and  taking 
into  account  likewise  the  results  of  previous  purulent  processes  in  the 
middle  ear,  if  any,  the  surgeon  may  avoid  the  opprobrium  of  attempt- 
ing to  cure  by  treatment  a  case  that  can  be  alleviated  only.  The 
mistake  is  often  made  by  resorting  to  measures  strictly  local,  or,  at 
furthest,  of  including  the  throat. 

In  laying  out  a  plan  of  treatment,  we  shall  find  in  a  very  consider- 
able number  of  the  more  important  cases,  where  there  are  distressing 
symptoms  of  autophonia,  noises  in  the  ear,  and  deafness  to  greater  or 
less  extent,  that  the  consideration  of  mental  disturbance  is  of  the 
utmost  importance.  Thus,  depression  from  worry  or  overwork  or 
undue  excitement  should  be  eliminated,  if  possible,  from  the  causative 
influences.  Methods  of  diverting  the  patient's  mind  need  not  be  gone 
into  here;  the  success  attending  the  medical  adviser  in  any  particular 
case  depends  on  his  own  resources  in  this  direction. 

The  condition  of  the  mouth  should  not  be  overlooked,  as  it  often 
is,  when  the  naso-pharynx  is  examined.  Carious  teeth,  which  have 
been  stopped  where  the  pulp  has  been  removed  or  is  irreparably  dis-- 


256  OTITIS   MEDIA   CHRONICA. 

eased,  may  be  the  source  of  much  danger;  this  is  especially  liable  to 
be  the  case  in  run-down  subjects,  and,  in  considering  the  advisability 
of  retaining  such  teeth  in  the  mouth  for  the  purpose  of  masticating, 
the  disadvantages  in  nearly  all  cases  outweigh  any  possible  benefit. 
The  reader  will  find,  however,  the  importance  of  decayed  teeth,  etc., 
as  factors  in  the  production  of  aural  diseases  fully  discussed  in  Chap- 
ter VII. 

The  sympathetic  relations  of  dental  irritation  with  acute  processes 
in  the  ear  have  already  been  alluded  to;  their  continuance,  even  when 
imperceptible  to  the  patient,  may  keep  up  aural  irritation  until 
trophic  changes  manifest  themselves  in  that  organ.  The  writer,  per- 
haps, has  dwelt  here  and  elsewhere  upon  this  subject  with  seeming 
prolixity,  but  its  importance  from  his  point  of  view  can  scarcely  be 
overestimated,  and  the  success  in  treatment  that  has  often  followed 
the  removal  of  such  sources  of  irritation  has  been  too  manifest  to  him 
to  admit  of  any  doubt  as  to  its  necessity. 

The  naso-pharynx  should  come  under  treatment  along  with  the  ear 
in  all  cases,  for  one  cannot  be  successfully  treated  without  the  other; 
moreover,  in  a  certain  sense,  the  affections  of  these  regions  are  to 
some  extent  retro-active  in  their  sympathetic  relationship  to  each 
other,  since  we  must  regard  the  area  of  expanded  mucous  membrane 
at  either  extremity  of  the  Eustachian  tube  as  separate  organs  in 
name  as  well  as  in  special  nerve  distribution. 

During  the  acute  exacerbations  which  temporarily  increase  deafness, 
and  thus  bring  the  patient  to  our  notice,  treatment  should  be  the 
same,  tentatively  at  least,  as  for  an  otitis  media  acuta. 

Of  the  more  remote  regions  likely  to  affect  the  patient,  as  the 
stomach,  uterus,  etc.,  nothing  need  be  said  here  further  than  that 
they  should  not  be  overlooked  where  the  case  is  under  consideration, 
whether  in  council  with  the  family  medical  attendant  or  otherwise. 

Having  suggested  what  the  general  course  should  be,  there  is  but 
little  remaining  to  be  said  about  treatment.  Inflation  of  the  ear  by 
means  of  Politzer's  valuable  method  may  be  of  service  in  some  cases 
for  loosening  up  slight  fixation  of  the  mechanism  and,  perhaps,  also 
in  hastening  the  reabsorption  of  undue  accumulation  of  serum  or 
mucus.  It  should  not  be  resorted  to  with  such  frequency  as  to 
endanger  tension  of  the  mechanism,  an  accident  that  might  occur 
where  the  Eustachian  tube  was  widely  expanded. 

The  hygienic  management  of  chronic  catarrhal  inflammation  of  the 
middle  ear,  though  mentioned  last,  is  first  in  importance;  it  should 
embrace  attention  to  both  the  individual  and  his«urrounding,  namely, 
to  the   quality  and  quantity  of  food  taken,  bathing,  clothing,  and 


OTITIS    MEDIA    SYPHILITICA.  257 

exercise,  and  to  the  ventilation  and  heating  ox  habitations,  etc.,  as 
well  as  to  the  vicissitudes  of  climate.  All  of  these  matters  have  been 
more  or  less  touched  on  elsewhere. 

In  regard  to  surgical  measures  in  cases  of  chronic  catarrhal  otitis 
media,  the  reader  may  consult  Chapter  XVII. 

OTITIS  MEDIA  SYPHILITICA. 

Subjects  of  secondary  syphilis  are  liable  to  invasions  of  a  specific 
nature  affecting  the  mucous  tract  of  the  middle-ear,  and  arising  for 
the  most  part  concurrently  with  hyperasmia  or  subacute  (catarrhalo 
inflammation  of  the  organ. 

Both  ears  are  usually  affected  simultaneously,  though  not  always 
in  the  same  degree.  Among  none  of  the  cases  coming  under  the 
author^s  observation  has  either  ear  altogether  escaped. 

Objective  Symptoms.  The  visible  anatomical  appearances  of  the 
ear  are  not  particularly  characteristic,  and  are  by  no  means  com- 
mensurate with  the  gravity  of  the  trouble.  The  inner  end  of  the  ex- 
ternal auditory  canal  is  often  somewhat  hyperaemic;  the  epidermis  of 
this  region,  and  of  the  drum-head,  may  exfoliate,  the  membrane 
having  a  thickened,  opaque,  and  lustreless  appearance.  Sometimes 
where  the  Eustachian  tubes  are  closed,  in  consequence  of  inflam- 
mation at  either  their  pharyngeal  or  tympanic  orifices,  the  drum- 
head will  be  retracted,  and  consequently  more  hyperasmic  than  other- 
wise. Usually  the  tympanum  contains  no  fluid,  as  the  writer  has 
found  by  performing  paracentesis. 

Subjective  Symptoms  and  Course.  The  invasion  is  characteristic, 
being  usually  sudden  and  the  deafness  absolute. 

In  one  case,  the  invasion  was  so  rapid  that,  although  hearing  was  good 
in  one  ear  at  night  on  going  to  bed,  when  the  patient  awoke  the  fol- 
lowing morning  it  was  entirely  gone.  The  other  ear  had  two  years 
previously  become  deaf  ^K\i\\  even  greater  suddenness.  The  patient 
experienced  a  detonation,  which  he  compared  to  a  pistol  shot,  and 
vertigo  and  vomiting  immediately  preceding  both  attacks. 

Pain  is  seldom  experienced,  though  in  some  instances  otalgia, 
due  to  reflected  irritation,  as  from  defective  teeth,  occurs.  The 
autophonia  and  noises  in  the  ear  are  very  often  almost  unbearable. 
The  following  case  presents  some  of  the  characteristic  symptoms  of 
the  disease: 

Patient,  a  male,  31  years  of  age.  with  the  history  of  constitutional 
syphilis,  contracted  some  six  months  before.     Fifty  days  before  being 
seen  by  the  author,  he  had  suddenly  become  very  deaf,  and  at  the 
17 


258  OTITIS    MEDIA    SYPHILITICA. 

feame  time  was  much  afflicted  with  frontal  headache  and  vertigo.  No 
deafness  had  been  noticed  previous  to  this  attack.  Both  ears  seemed 
to  be  similarly  affected  as  regards  the  deafness. 

Patient  has  pains  in  back  of  head,  extending  to  neck  and  ears. 
There  is  decided  uaso-pharyngeal  catarrh.  Many  of  his  teeth  are 
carious.  The  general  condition  of  the  patient  was  fair,  how^ever, 
under  the  circumstances.  The  inner  ends  or  extremities  of  both 
meatus  are  hyperaemic.  The  drum-heads  are  not  thickened  in  ap- 
pearance, but  have  a  humid  aspect.  Extending  to  the  dermoid  layer 
of  both  membranes  from  the  meatus,,  is  the  same  moderately  hyper- 
aemic condition  characterizing  the  latter.  The  hyper^emia  is  more 
marked  about  the  short  processes,  and  it  extends  down  along  the 
malleus  handles.  The  membranes  were  furtliermore  retracted,  espe- 
cially the  right  one.  Much  tinnitus  aurium  existed.  Patient  cannot 
understand  anything,  even  when  shouted.  Intensely  loud  tones  of 
high  or  low  pitch  are  heard,  and  best  heard  when  in  a  noise.  He  can 
hear  his  own  voice,  and  can  sing  in  tune.  Tissue-conduction  exists 
for  the  tuning-fork  when  placed  on  the  skull. 

Under  a  treatment  of  iodide  of  potassium,  together  with  inunctions 
of  mercurial  ointment,  followed  later  by  the  mixed  treatment  inter- 
nally, the  hearing  improved  so  much  that  loud  voices  could  be  heard 
and  understood  in  the  right  ear  at  a  distance  of  six  feet  or  more. 

Out  of  118  cases  of  syphilis  affecting  the  ear,  seen  by  the  writer, 
86  cases  occurred  in  connection  with  otitis  media  (catarrhalis)  chron- 
ica, and  9  cases  in  acute  non-suppurative  inflammation  of  the  middle 
ear.         , 

The  accompanying  vertigo  and  noises  in  the  ear  would  seem  to  be 
due  to  pressure  upon  the  fenestra  ovalis  or  rotunda  from  the  drum. 
To  what  extent  the  inner  ear  itself  may  be  directly  affected  in  these 
cases  cannot  be  discussed  in  this  connection.  The  writer  surmises, 
however,  that  nervous  irritation,  transmitted  from  the  middle  ear, 
may  account  for  some  of  the  phenomena,  without  supposing  that  in- 
flammation of  the  auditory  nerve  exists. 

Pathology.  It  may  be  surmised  that,  in  the  more  severe  cases, 
granuloma,  or  circumscribed,  round-cell  infiltration  takes  place 
within  the  tympanum;  that  the  invasion  is  rapid,  and  that  the  con- 
ductive apparatus  is  thus  prevented  from  performing  its  movements, 
owing  to  the  particular  manner  of  fixation  that  occurs.  A  more  or 
less  rapid  deposition  of  lymph  probably  takes  place  in  all  of  these 
cases,  causing  almost  instantaneous  or  greatly  increased  deafness  from 
fixation  of  the  ossicles. 

Diagnosis.  In  the  more  pronounced  cases  this  is  not  difficult,  though 
sometimes  syphilitic  infection  is  denied,  in  which  event  confirmatory 
evidence  may  be  found  on  making  a  physical  examination  of  the  pa- 
tient.    From  his  own  experience,  the  writer  believes  that   specific 


OTITIS    MEDIA    SYPHILITICA.  259 

invasions  of  the  ear  milder  than  those  described  above  frequently  occur, 
since  we  have  hitherto  only  had  attention  directed  to  cases  where 
deafness  has  been  total,  or  almost  so. 

Prognosis.  In  the  more  grave  cases,  very  little  improvement  usually 
occurs  from  treatment;  but  when  seen  early,  the  less  severe  cases  are 
more  or  less  remediable.  In  all  cases  where  syphilis  complicates 
middle  ear  inflammation,  the  prognosis  may  be  said  to  be,  in  con- 
sequence, less  favorable. 

Treatment.  No  local  treatment  is  indicated  beyond  the  moderate 
inflation  of  the  drums  by  Politzer's  method.  Constitutional  measures 
should  embrace  remedies  known  to  be  of  service  in  secondary  syphilis, 
viz.,  mercur}',  and  iodide  of  potassium.  The  biniodide  in  small 
doses  of  ^^ai  a  grain,  has  been  found  beneficial,  given  four  times  a 
day.  The  writer  does  not  believe  that  the  excessively  large  doses  of 
iodide  of  potassium  sometimes  given  are  always  judicious;  from 
three  to  five  grains  of  the  iodide,  given  in  connection'  with  -^^  of  a 
grain,  or  even  less,  of  the  bichloride  of  mercury,  has  been  attended 
with  satisfactory  results  in  his  experience.  It  must  not  be  forgotten 
that  the  patient,  in  these  cases,  is  suffering  from  inflammation  of  the 
middle  ear.  modified  by  the  syphilitic  dyscrasia,  nor  that  it  is  also  im- 
portant to  attend  to  any  existing  oral  or  naso-pharyngeal  irritation 
that  may  be  present. 


CHAPTER  XIII. 

OTITIS   MEDIA   SUPPUKATIVA. 
Acuta;    Chronica. 

OTITIS   MEDIA   SUPPURATIVA  ACUTA. 

This  form  of  inflammation  of  the  middle  ear  is  one  affecting  the 
mucous  and  submucous  lining  of  this  region  and  which  is  attended 
by  the  formation  of  pus.  It  is  ushered  in  similarly  to  acute  non-sup- 
vpurative  inflammation  of  this  region,  and  may  prove  to  be  of  as  brief 
duration  as  that  process.  Thus,  in  the  beginning,  especially  where 
the  atrium  is  alone  or  chiefly  affected,  the  trouble  is  often  never 
brought  to  the  otologist's  attention  ;  indeed,  unless  there  is  much 
pain  or  pronounced  deafness,  is  not  always  always  considered  impor- 
•tant  enough  to  consult  the  family  physician  concerning  it.  This  af- 
fection may,  furthermore  resemble  the  acute  otitis  media,  inasmuch 
as  it  frequently  comes  and  goes,  again  and  again,  as  the  causative  in- 
fluences appear  and  disappear,  before  it  is  thought  to  be  serious 
enough  to  require  medical  aid.  It  is,  in  fact,  too  often  regarded  as 
an  "earache  only,"  which  should  be  left  to  nature  to  get  well!  Sup- 
purative inflammation,  however,  in  many  instances  commences  in  a 
severe  form,  involving  the  mucous  and  periosteal  layer  ;  and  it  is  by  no 
means  always  limited  to  that  portion  of  the  organ  most  easily  seen, 
namely  the  membrana  vibrans,  and  the  atrium  of  the  tympanum, 
which  lies  immediately  beyond  the  former,  but  the  attic  of  the  tym- 
panum, the  antrum,  mastoid,  and  neighboring  cellules  will  often  also 
be  found  affected.  Inflammation  of  the  periosteum,  so  often  present, 
constitutes  the  chief  feature  of  interest  in  these  cases,  since  it 
underlies  the  entire  mucous  tract  of  the  ear  and,  extending  out- 
wardly, envelopes  the  external  auditory  canal  and  peri-auricular 
surface  of  the  temporal  bone.  The  periosteum,  when  inflamed,  may 
deprive  a  large  area  of  osseous  tissue  of  its  source  of  nutrition,  and 
the  importance  of  the  case,  therefoi'e,  bears  a  direct  relation  to  the 
gravity  of  the  invasion  and  the  patient's  power  of  resistance. 


OTITIS    MEPIA    SITPPUEATIVA    ACUTA. 


261 


Etiology.  In  considering  the  etiology  of  the  purulent  form  of  acute 
inflammation  of  the  middle  ear,  it  should  be  kept  in  mind  that  the 
initial  pathological  phenomena  are  similar  to  or  identical  with  those 
of  the  acute  non-suppurative  affection  already  noticed.  It  is  of  fre- 
quent occurrence  in  the  first  weeks  of  infancy.  Thus  among  628 
cases  of  acute  purulent  inflammation  of  which  records  were  made  by 
the  author,  were  twenty-eight  under  one  year  of  age,  as  follows  : 


Age 

Six  weeks 

Nine  weeks  

Ten  weeks 

Two  months 

Three  months 

Four  months 

Five  months 

Seven  months 

Eight  months. 

Nine  months 

Ten  months  

Eleven  months 

Total 


Males. 

Females. 

Total. 

3 

3 

i 

1 

1 

1 

2 

•6 

5 

2 

2 

2 

2 

1 

i 

2 

2 

1 

8 

1 

1 

1 

i 

2 

2 

1 

3 

2 

1 

3 

16 

12 

28 

In  a  large  proportion  of  children  under  ten  years  of  age  a  general 
inflammatory  condition  of  the  upper  air-tract  is  especially  notable. 
The  disease  is  sometimes  accompanied  by  gastric  disturbance,  rhinitis, 
earache  and  fever  showing  a  tendency  to  periodicity.  Such  a  condi- 
tion in  young  children,  who  are  unable  to  describe  their  symptoms 
intelligently,  is  frequently  termed  ''malarious,''  the  advent  of  an 
aural  discharge  first  disclosing  the  nature  of  the  affection. 

Table  shoiving  age  and  sex  in  628  cases  of  acute  purulent  otitis 

media. 


Age. 

Under  1  year  of  age,  as  given  above 

Between  1  and  2  years , 

Between  2  and  3  years 

Between  3  and  4  years 

Between  4  and  5  years 

Between  5  and  lO  years , 

Between  10  and  20  years 

Between  20  and  80  year.s 

Between  30  and  40  years 

Between  40  and  50  years 

Between  50  and  60  years 

Between  60  and  70  years 

Between  70  and  80  years. 

Over  80  years  . 

Total 


Males. 

Females. 

Total. 

16 

12 

28 

6 

13 

19 

11 

13 

24 

10 

8 

18 

8 

13 

21 

21 

29 

50 

78 

26 

104 

117 

35 

152 

67 

32 

99 

89 

24 

63 

28 

9 

32 

11 

3 

14 

2 

1 

3 

1 

1 

410 

218 

628 

262  OTITIS    MEDIA    SUPPURATIVA    ACUTA. 

Many  of  the  causative  injlue)ices  giving  rise  to  this  trouble  are,  it 
will  be  seen,  similar  to  those  described  in  connection  with  acute  non- 
purulent otitis  media ;  prominent  among  these  were  syphilis,  scarla- 
tina and  rubeola,  maltreatment  of  various  kinds  and  traumatism, 
exposure,  and  sea-bathing.  The  latter  was  among  the  most  frequent 
of  the  active  causative  influences  in  the  above  recorded  cases,  since  in 
nearly  a  sixth  part  of  the  total  number  of  these  patients  the  disease 
had  been  produced  by  sporting  in  the  sea.  Among  predisposing 
causes  and  conditions  present,  irritation  from  dentition,  diseased 
teeth,  catarrhal  states  of  the  uaso-pharynx,  enlarged  tonsils,  etc., 
existed  in  at  least  half  the  number  ;  conditions  to  be  borne  in  mind 
in  treatment. 

Space  will  not  permit  a  more  detailed  account  of  the  causative  in- 
fluences in  acute  purulent  inflammation  of  the  middle  ear  ;  for  fur- 
ther data  the  reader  may  consult  the  author's  paper  on  "  The  Diag- 
nosis and  Treatment  of  Acute  and  Chronic  Purulent  Inflammation  of 
the  Middle  Ear  Tract  and  their  Complications,"  read  before  the 
American  Otological  Society,  July  20th,  186G,*  in  which  will  be  found 
tabulated  lists  of  active  and  predisposing  causes,  symptoms,  etc. 

Too  much  stress  cannot  be  laid  on  the  injurious  effects  in  many  in- 
stances produced  by  sea-bathing,  Russian,  Turkish  and  other  baths, 
and  to  the  entrance  of  fluids  propelled  along  the  Eustachian  tube  in 
sea-bathing  or  from  the  use  of  the  nasal  douche.  It  happens  very 
often  that  the  attic  only  is  affected  from  these  causes.  This  can 
readily  be  understood  when  it  is  kept  in  mind  that  the  tympanic  ori- 
fice of  the  Eustachian  tube  opens  by  a  free  sweep  into  the  attic  as  well 
as  into  the  atrium,  and  that  fluids  traversing  the  canal  with  consider- 
able momentum  would  follow  the  upward  sweep  of  the  tympanic  em- 
brasure rather  than  gravitate  downward.  Moreover  the  presence  of 
irritating  fluids  seems  to  be  much  better  borne  in  the  lower  than  in 
the  upper  part  of  the  tympanum. 

Objective  Symptoms.  It  will  generally  be  found  on  examining  the 
ear  at  the  beginning  that  the  membrana  flaccida  is  red,  the  vascular 
turgescence  extending  above  on  to  the  external  auditory  canal,  and 
perhaps  downward  about  the  short  process  of  the  malleus.  In  favor- 
able cases,  a  regressive  stage  may  begin  at  this  time,  but  frequently 
the  inflammation  extends  from  the  attic  along  beneath  the  margo 
tyiripanicus  of  the  auditory  plate,  and  is  attended  with  effusion  of 
serum  or  blood;  this  raises  up  the  membrana  flaccida  and  the  adjacent 

'  Transactions  of  the  American  Otological  Society.  Sixteenth  Annual 
Meeting.    Vol.  3,  Part  5.     18S6. 


OTITIS    MEDIA    SUPPURATIVA    ACUTA.  263 

integument  of  the  external  auditory  canal,  which  is  quite  loosely- 
attached  to  the  outer  surface  of  the  auditory  plate.  In  some  instances 
the  bulging  out  of  these  parts  is  sufficient  to  form  a  sac,  which  en- 
tirely conceals  the  membrana  tympani,  or  may  even  entirely  fill  the 
canal  and  present  at  the  lumen  as  a  purplish  tumor.  It  would  seem 
that,  in  some  instances,  rupture  of  blood-vessels  belonging  to  the 
tympanic  plexus  takes  place,  giving  rise  to  the  sudden  extravasation 
of  a  large  amount  of  sanguineous  fluid.  The  tumor  thus  formed 
does  not  always  communicate  with  the  attic  at  first,  although  later 
on  it  may  do  so. 

The  appearance  of  the  drum-head  to  the  inexperienced  observer 
often  gives  but  an  inadequate  idea  of  the  gravity  of  the  case,  yet  in 
the  more  severe  cases  some  breaking  down  of  the  membrana  vibrans 
occurs,  more  than  one  perforation  frequently  resulting. 

Subjective  Symptoms  and  Course.  Infants,  who  are  especially  sub- 
ject to  reflex  and  vaso-motor  ear  disturbances  during  dentition,  head 
catarrh,  and  gastric  derangements,  often  give  fewer  pathognomonic 
indications  than  older  persons.  A  discharge  from  the  ear,  even  with 
peri-auricular  swelling,  may  thus  take  place  without  any  observable  pre- 
monitory symptoms,  and  quite  often  spontaneous  recovery  follows  so 
promptly  that  an  incrustation  of  muco-pus  in  the  concha  of  the 
affected  ear,  or  a  stain  upon  the  linen,  constitutes  the  only  evidence 
of  its  occurrence. 

Infants  are,  of  course,  unable  to  make  known  in  an  intelligible 
manner  the  distress  experienced  from  deafness  and  autophonia,  and 
the  fretfulness  consequent  upon  aural  inflammation  may  be  attributed 
to  teething  or  other  causes;  it  may  often  be  inferred,  however,  that 
suffering  from  these  phenomena  or  from  pain  is  experienced  when 
the  child  cries  and  puts  the  hand  significantly  up  to  the  ear.  The 
exhaustion  resulting  from  worry  and  pain  is  sometimes  very  great, 
and  may  divert  attention  from  the  actual  seat  of  disease  to  the  brain 
itself,  which,  indeed,  in  these  cases  is  only  too  liable  to  become 
affected  by  extension  of  the  aural  trouble.  In  older  persons  inflam- 
mation of  the  atrium  of  the  tympanum  is  usually  a  much  more  pain- 
ful affectioji,  the  subjective  phenomena  contributing  to  the  distress, 
though  the  extent  of  these  depends  on  the  sensitiveness  of  the  pa- 
tient— very  grave  trouble  not  infrequently  escaping  detection,  from 
absence  of  suffering.  Rupture  of  the  membrana  vibrans  as  a  result 
of  disintegration,  or  the  pressure  of  secretions,  or  from  both  causes 
combined,  may  take  place  in  a  few  hours  or  after  several  days — pain 
becoming  less  or  ceasing  altogether.     The  subjective  symptoms,  how- 


204  OTITIS    MEDIA    SUPPUKATIVA   ACUTA. 

ever,  do  uot  always  disappear  with  the  subsidence  of  paiu;  they  may 
even  become  more  unendurable. 

But  inflammation  in  many  instances  does  not  go  on  to  perforation 
of  the  drum-head,  although  suppuration  may  take  place. 

There  is  always  some  deafness  and  autophonia  in  purulent  inflam- 
mation of  the  tympanum;  when  the  attic  alone  is  affected  there  is 
less  than  when  the  atrium  is  the  principal  seat  of  the  trouble,  since 
thete  is  usually  less  interference  with  excursive  movements  of  the 
membrana  vibrans.  Any  inflammation  of  the  drum,  however,  is 
liable  to  give  rise  to  abnormal  transmission  of  sound,  which  if  heard 
loudly  is  yet  wanting  in  distinctness.  If  great  tension  of  the  trans- 
mitting mechanism  exists,  low  tones,  as  the  rumbling  of  loaded  trucks 
or  horse  cars,  are  heard  as  high  ones,  and  sometimes  give  rise  to  pain- 
ful sensations. 

These  phenomena  pertain  to  derangements  of  the  middle  ear,  and 
do  not  resemble  disturbances  of  the  physiological  function  of  the 
auditory  nerve.  When  the  nerve  is  impaired  by  extension  of  inflam- 
mation to  its  terminal  filaments  from  the  middle  ear,  or  by  pachy- 
meningitis, there  is  diminished  perception  of  sound  impressions, 
whilst  disturbances  (central)  at  its  origin  in  lepto-meningitis,  and 
perhaps  in  nervous  exhaustion,  give  rise  to  dysacousma  or  cerebral 
hyperaesthesia  (painful  hearing)  and  vertiginous  phenomena. 

Pain  in  a  large  number  of  instances  is  generally  distressing  in  the 
extreme.  This,  however,  is  by  no  means  always  a  reliable  symptom, 
since  its  manifestation  depends  on  the  physical  susceptibility  of  the 
individual;  the  fortitude  and  apathy  of  both  children  and  adults  often 
being  in  this  regard  quite  remarkable,  and  unless  duly  taken  into 
account  may  lead  us  to  underrate  the  gravity  of  the  case.  Sensitive 
and  neuropathic  persons,  on  the  contrary,  suffer  greatly  from  com- 
paratively slight  causes.  Intense  pain  may  accompany  either  inter- 
nal or  external  periosteal  inflammation,  and  when  these  co-exist  the 
suffering  is  no  less  than  in  pachymeningitis,  from  which  differentia- 
tion is  difficult,  if  not  impossible. 

Simple  Inflammation  of  the  Atrium  may  extend  itself  no  further, 
but  so  soon  as  the  attic  takes  on  inflammation  the  process  is  nearly 
always  propagated  inwardly  to  the  antrum  and  cellules,  and  to  a 
greater  or  less  extent  outwardly  along  the  canal,  over  the  cortex  of 
the  mastoid  and  periauricular  region  generally.  The  symptoms  are, 
of  course,  much  more  pronounced  when  both  interior  and  exterior 
parts  are  affected  at  the  same  time,  and  the  co-existence  of  periosteal 
inflammation  of  the  mastoid  cellules  and  cortex  is  almost  certain  to 
eventually  cause  caries  of  the  bone.     Inflammation  is  liable  to  extend 


OTITIS    MEDIA    SUPPUKaTIVA   ACUTA.  265 

itself  from  the  tympanum  iu  this  manner  in  nearly  all  cases,  but  the 
attendant  symptoms  and  course  of  the  disease  depend  greatly  on  the 
age  and  condition  of  the  patient:  in  other  words,  its  slight  or  severe 
phases  are  due  to  constitutional  influences. 

Inflamimtiion  of  the  Attic  may  develop  consecutively  to  inflamma- 
tion of  the  atrium,  and,  of  course,  both  may  be  affected  simultane- 
ously. Inflammation  of  the  attic,  whether  direct  or  by  extension 
from  the  atrium,  may,  when  the  outlets  therefrom  remain  free,  pursue 
a  favorable  course  without  extending  further;  most  frequently,  how- 
ever, the  trouble  extends  not  only  outwardly,  as  already  described, 
but  owing  to  the  swelling  that  takes  place,  the  outlets  into  the 
Eustachian  tube  and  atrium  become  obstructed,  and  pent-up  secre- 
tions greatly  aggravate  the  case.  The  mastoid  antrum  and  cellules 
become  involved,  and  pain  is,  for  the  most  part,  severe. 

In  inflammation  of  the  atrium,  as  has  been  remarked,  the  drum- 
head, unless  greatly  thickened  by  former  inflammatory  processes, 
generally  gives  way  to  slight  pressure,  and  relief  is  immediate  and 
complete.  When  the  attic  is  involved,  however,  the  secretions  are 
much  more  liable  to  be  retained,  and  suffering  may  thus  increase  from 
hour  to  hour,  and  day  to  day,  unless  liberated  by  an  operation. 

Fei'iostitis  interna  et  externa.  By  this  is  to  be  understood  an 
extension  of  the  inflammation  of  the  periosteum  of  the  middle  ear 
inwardly  to  the  deeper  parts  of  the  middle  ear  tract,  and  outwardly 
to  the  walls  of  the  external  auditory  canal,  the  mastoid  cortex,  and 
even  to  the  entire  circumauricular  region.  Sometimes  the  process 
extends  mainly  in  one  direction  onl}';  thus,  when  the  antrum,  mas- 
toid, and  adjacent  cellules  are  affected,  we  have  to  deal  with  periostitis 
interna;  when  the  walls  of  the  external  auditory  canal  and  outer 
surface  of  the  temporal  bone  are  the  seat  of  the  trouble,  it  is  described 
as  periostitis  externa. 

The  region  affected  in  periostitis  interna  is  a  much  more  important 
one  than  that  ordinarily  invaded  during  the  progress  of  periostitis 
externa.  Thus  the  extensive  mucous  tract  of  the  middle  ear  consti- 
tutes a  large  interosseous  cavern,  separated  from  the  dura  mater  by 
a  thin  plate  of  bone  only.  Between  the  walls  of  this  cavity  and  the 
brain,  numerous  nerves,  blood-vessels,  and  lymphatics  anastomose,  by 
means  of  wliich  the  suppurative  process  may  readily  pass  from  on'e 
region  to  the  other. 

Periostitis  externa  may  develop  where  the  middle  ear  has  not  been 
seriously  affected;  the  periosteal  cortex  may  thus  become  intensely 
inflamed  without  implication  of  the  mastoid  cellules.  Of  this,  how- 
ever, more  will  be  said  later  on. 


26G  OTITIS   MEDIA    SUPPURATIVA    ACUTA. 

Death  occurs  in  infancy  probably  from  suppurative  phlebitis  or 
pachymeningitis,  consequent  on  inflammation  of  the  ear,  much  oftener 
than  is  suspected,  even  when  caries  of  the  bone  or  pent  up  secretions 
could  not  be  detected.  The  frequency  of  the  presence  of  thickened 
dura  mater  over  the  tegmen  on  post  mortem  is  notable,  and,  doubt- 
less, many  obscure  cases  of  deaf- mutism  owe  their  origin  to  unsus- 
pected injury  of  the  auditory  nerve  in  this  manner. 

THE   OCCURRENCE    OF    GRAVE    CASES    OF    ACUTE    PURULENT 
INFLAMMATION    OF   THE  MIDDLE    EAR. 

Tiie  importance  of  certain  grave  cases  of  acute  purulent  inflam- 
mation of  the  middle  ear  is  thought  to  be  of  sufficient  interest  to 
demand  a  separate  consideration,  as  the  deep  tissues  of  the  neck  on 
the  one  hand,  and  the  cranial  cavity,  through  sympathy  or  extension 
via  blood  vessels  or  lymphatics,  on  the  otlier  hand,  are  more  liable  to 
be  involved. 

In  acute  inflammation  of  the  attic,  unless  a  regressive  course  is 
established,  the  secretions  are  liable  to  become  imprisoned  by  closure 
of  the  outlets;  this,  together  with  the  extension  of  periosteal  inflam- 
mation outwardly  along  the  roof  of  the  adjacent  canal,  is  attended 
by  infiltration  or  suppuration;  the  membrana  flaccida  and  adjacent 
integument  become  red  and  tumefied,  and  in  the  more  severe  cases 
their  detachment  from  the  tympanic  ring  and  auditory  plate  takes 
place.  The  secretions  now  seek  an  outlet  from  the  attic  in  this 
direction,  distending  the  tumor  more  and  more.  There  is  not  the 
tendency  to  rupture  of  the  sac  thus  formed  as  when  the  lower  portion 
of  the  drum-head  is  distended,  since  the  former  is  not  only  much 
thicker,  but  being  loosely  attached  permits  secretions  to  easily  bur- 
row underneath.  The  liberated  secretions  now  dissect  their  way  out, 
first  along  the  osseous  walls  of  the  canal  and  then  along  over  the 
temporal  bone  in  various  directions,  most  frequently,  however,  pos- 
teriorly. In  this  manner  the  formation  of  what  is  known  as  a 
Dissecting  T'ympano-Mastoid  Abscess  takes  place. 

Sometimes  along  with  the  spreading  periostitis  externa,  the  subcu- 
taneous connective  tissue  breaks  down  extensively,  and  an  enormous 
periauricular  abscess  is  formed,  limited  only  by  the  temporal  fascia; 
in  other  instances  again  the  abscess  is  limited  to  the  region  of 
the  membrana  flaccida,  or  to  the  mastoid  process.  These  dissecting 
abscesses,  in  the  writer's  own  experience,  occur  most  frequently 
in  young  children,  as  would  be  expected  when  the  loose  attachment 
of  the  drum-head  to  the  auditory  plate  at  this  age  is  considered.     In 


OTITIS   MP]DIA   SUPPUKATIVA.    ACUTA.  267 

such  cases  the  canal  and  j)erianricular  region  sometimes  swell  up 
rapidly,  and  subside  again  as  quickly,  without  abscess  formation.  In 
the  adult  where  rhinitis  sicca  precedes  the  aural  trouble,  the  mucous 
membrane  of  the  middle  ear  tract  takes  on  similar  action,  the  retained 
secretions  being  extremely  fetid.  There  is  a  tendency  to  chronicity 
in  these  cases,  without  much  pain. 

It  is  well  to  remember  that  in  some  cases  of  dissecting  tympano- 
mastoid abscess  the  larger  vessels  of  the  mallear  plexus,  as  it  would 
seem,  are  ruptured,  and  a  sanguineous  cyst  is  formed  by  separation  of 
the  dermic  layer  from  the  drum-head  and  adjacent  walls  of  the  canal. 
These  tumors  vary  in  size  from  a  small  bleb  to  that  of  a  sac  entirely 
filling  the  external  auditory  canal  and  preventing  any  inspection  of 
deeper  parts. 

Sometimes,  after  evacuation  of  the  tumor,  the  integumentary  walls 
of  the  canal  collapse  in  consequence  of  their  separation  from  the 
upper  portion  of  the  tympanic  ring.  In  young  children,  owing  to 
the  greater  flaccidity  of  the  parts,  detachment  of  the  entire  membra- 
nous wall  from  the  tympanic  ring  may  take  place,  as  shown  by  the 
laxity  of  the  canal  and  gurgling  of  secretions  at  its  inner  end  on 
traction  upon  the  auricle.  In  these  cases  there  will  usually  be  found 
caries  of  the  tympanic  walls  and,  in  some  instances,  ulceration  of  the 
canal. 

With  periostitis  externa,  there  is  usually  more  or  less  asymmetrical 
prominence  of  the  auricle  on  the  affected  side. 

These  dissecting  tympano-mastoid  abscesses  usually,  but  not  invari- 
ably, burrow  along  the  superior-posterior  wall  of  the  external  auditory 
canal;  not  unfrequently,  however,  they  follow  the  superior-anterior 
wall.  In  the  first  named,  purulent  matter  is  generally  found  to  finally 
make  its  appearance  over  the  mastoid  process;  in  the  latter,  above  or 
in  front  of  the  auricle.  Sometimes  the  entire  peri-auricular  region  is 
involved,  and  in  the  more  severe  cases  pus  will  burrow  from  the 
mastoid  region  posteriorly  beneath  the  deep  fascia  of  the  neck  as 
far  as  the  median  line  of  the  occiput  and  even  beyond,  or  downwards 
beneath  the  sterno-mastoid  muscle  and  along  the  fascial  layers  under- 
neath the  trachea. 

The  pointing  of  a  tympano-mastoid  abscess  may  take  place,  further- 
more, on  the  superior  or  posterior  wall  of  the  external  auditory  canal 
near  the  tympanum  in  some  cases,  even  when  at  the  same  time 
bulging  occurs  at  some  point  about  the  auricle. 

Teat-like  outlets,  in  many  instances,  sooner  or  later  form  in  the 
drum-head,  especially  if  the  orifice  be  in  the  membrana  flaccida.  This 
process  generally  marks  the  beginning  of  a  distinctly  favorable  change 


268  OTITIS   MEDIA    SUPPURATIVA   ACUTA. 

in  the  course  of  the  disease,  and,  iii  the  more  healthy  subjects,  recovery 
is  from  this  time  on  usually  rapid. 

Discharge  from  the  tympanum  not  infrequently  finds  an  outlet  at 
some  point  near  the  drum-head,  where  a  dissesting  abscess  has  opened 
on  the  posterior  wall  of  the  external  auditory  canal;  the  teat-like 
form  of  such  openings  is  not  so  well  marked  as  those  just  described. 
These  sinuses  are  liable  to  be  confounded  with  those  which  furnish 
an  outlet  from  the  mastoid  cellules  in  this  locality,  but  the  latter  are 
usually  associated  with  fungosities  and  caries  of  the  bone. 

Secretions  from  the  tympanum  may  later  on,  when  suppuration  has 
taken  place  in  the  mastoid,  also  escape  by  passing  into  the  mastoid 
antrum,  thence  through  the  diseased  cellular  structure,  and  on  out 
through  a  sinus  in  the  cortex. 

The  unfavorable  progress  of  these  cases  occurring  in  broken-down 
subjects  is  shown  in  the  following: 

A  female,  aged  30,  came  for  the  relief  of  acute  purulent  inflamma- 
tion of  the  middle  ear  tract.  There  was  nausea  and  vomiting;  deep- 
seated  pain  in  the  mastoid,  occiput,  and  vertex.  She  was  a  broken- 
down  subject  living  under  very  bad  hygienic  conditions.  Examination 
showed  extensive  detachment  and  bulging  of  the  flaccid  membrane 
and  adjacent  walls  of  the  canal.  The  pent-up  secretions  caused  great 
tension  of  the  parts  and  gave  rise  to  the  symptoms  mentioned.  The 
purulent  matter  was  liberated  at  the  seat  of  bulging,  securing  ample 
drainage  and  relief;  as  the  discharge  lessened,  a  teat-like  formation 
appeared,  and  recovery  followed  in  two  months. 

Mrs.  B.  came  to  the  infirmary  suffering  from  the  results  of  four 
miscarriages  and  the  exsanguination  from  hemorrhage  following  a 
recent  abortion.  There  was  a  dissecting  tymnano-mastoid  abscess  and 
difficult  drainage,  consecutive  to  acute  purulent  inflammation  of  the 
middle  ear  tract.  Caries  of  the  auditory  plate  and  posterior  wall  of 
the  external  auditory  canal,  with  protruding  fungosities  from  a  sinus 
in  the  latter  existed.  Notwithstanding  repeated  and  free  incisions 
into  the  sac,  and  removal  of  the  presenting  fungosities,  recovery 
was  much  protracted. 

Diagnosis.  The  management  of  a  case  of  acute  inflammation  of 
the  middle  ear,  especially  in  children,  in  order  to  arrive  at  a  correct 
diagnosis  and  successfully  treat  the  patient,  will  require  both  patience 
and  skill.  When  a  case  of  this  kind  is  encountered,  the  suffering  and 
nervousness  of  the  child  will  generally  interfere  very  much  with  the 
examination;  and  when  the  domestic  establishment  is  anxious  and 
worried  from  sympathy  and  vigilant  nursing,  their  assistance  is  gene- 
rally a  hindrance  rather  than  an  aid.  Under  these  circumstances,  it 
will  be  often  necessary  to  bring  order  out  of  chaos  before  attempting 


OTITIS    MEDIA    SUPPURATIVA    ACUTA.  269 

to  make  an  examination.  A  little  firmness,  however,  and  the  service 
of  a  calm  attendant,  are  usually  sufficient  to  accomplish  this,  and 
tranquillize  the  patient.  During  the  temporary  lull  which  may  con- 
fidently be  expected,  and  while  the  patieut  is  firmly  held  in  the  atten- 
dant's lap,  the  required  examination  can  be  made. 

Whilst,  as  a  rule,  the  diagnosis  in  adults  is  not  difficult,  in  alarmed 
and  struggling  children  it  is  not  by  any  means  an  easy  matter 
always;  the  canal  may  be  naturally  narrow,  the  swelling  and  secre- 
tions obscuring  the  ]>arts.  Co-existing  exudative  dermatitis  of  the 
inner  end  of  the  canal  and  the  outer  layer  of  the  drum-head  is  liable 
to  conceal  the  parts,  and  thus  mislead  the  inexperienced  observer. 
Underneath  this  exudation,  the  removal  of  which  is  painful  and  dif- 
ficult, the  dermic  layer  of  the  drum-head  is  seen  to  be  dark  red,  and 
even  purplish  in  color;  later  on,  it  becomes  necrotic,  and  finally  ex- 
foliates. The  whitish  and  somewhat  inspissated  exudative  matter, 
which  sometimes  completely  fills  the  inner  end  of  the  canal,  has  been 
taken  for  "  diphtheria"  of  the  ear  by  some  authors. 

Tbe  gravity  of  these  cases  is  not  always  to  be  determined  by  the 
pain  experienced  or  the  appearance  of  the  fundus;  nor  can  a  differ- 
ential diagnosis  be  made  in  every  case  at  first. 

Pain  is  often  not  marked,  even  though  the  attic  be  involved  and 
periostitis  externa  present;  its  existence  or  non-existence  is,  there- 
fore, as  has  been  before  alluded  to,  often  a  question  of  temperament, 
and  indicating  rather  the  degree  of  tolerance  of  suffering  than  the 
extent  of  the  disease. 

The  pent-up  secretions  in  the  attic  usually,  however,  give  rise  to 
very  great  and  persistent  pain,  and  swelling  and  tenderness  are  ex- 
perienced about  the  peri-auricular  region. 

A  diagnosis  regarding  the  seat  of  the  disease  is  most  important, 
since  some  cases  are  so  simple  that  scarcely  any  other  treatment  is 
required  than  rest,  cleanliness,  and  attention  to  hygienic  measures; 
whilst,  on  the  other  hand,  others  are  to  be  included  among  the  more 
grave  affections  met  with  in  practice,  injismuch  as,  if  let  alone,  they 
may,  by  extension,  involve  deeper  lying  structures.  The  appearances 
of  the  drum-head  afford  a  useful  guide;  where  the  atrium  and  mem- 
brana  vibrans  are  the  principal  seat  of  inflammation,  the  latter  is  more 
or  less  red,  and  sometimes  bulging.  In  severe  cases,  as  already  stated, 
there  is  often  necrosis  of  the  dermic  layer,  which  then  has  a  dead, 
ashy  hue;  sometimes  this  desquamates,  leaving  a  purplish  surface 
more  or  less  rugous  in  look.  But  where  the  attic  is  also  affected,  or 
the  disease  is  mostly  confined  to  this  region,  the  membrana  vibrans 
may  exhibit  scarcely  any  of  the  above  conditions.     On  careful  exami- 


270  OTITIS   MEDIA    SUPPURATIVA    ACUTA. 

nation  of  the  parts,  however,  under  good  ilhiniination,  the  membrana 
flaccida  and  adjacent  walls  of  the  canal  will  be  found  reddened,  and 
the  mallear  plexus  of  blood-vessels  more  or  less  engorged. 

When  spontaneous  perforation  occurs  later  on  in  these  cases  of 
attic  inflammation,  the  opening  will  be  found,  as  a  rule,  in  the  mem- 
brana flaccida,  having  the  appearance  of  a  nipple,  through  which 
perhaps  a  small  drop  of  pus  may  be  observed  to  ooze.  The  nipple- 
like outlet  from  the  attic  through  the  membrana  flaccida  should  not 
be  mistaken  for  a  polypoid  growth,  though  a  polypus  may  subse- 
quently develop  from  the  mucous  membrane  and  present  through  this 
opening.  The  appearance  of  the  drum-head  is  not  always  pathogno- 
monic, even  in  the  earlier  stages  of  suppurative  inflammation. 
Though  it  be  found  bulging,  and  its  surface  more  or  less  red,  we 
are  not  sure  that  reabsorption  may  not  take  place;  and,  on  the 
contrary,  what  is  seemingly  a  mild  attack,  without  distention,  may, 
in  a  few  hours,  manifest  its  nature  by  a  copious  discharge  from  the 
ear.  Where  the  drum-head  is  thickened  by  previous  inflammation, 
it  does  not  yield  so  readily  to  pent-up  secretions. 

Pachymeningitis  and  cerebral  abscess  are  often  exceedingly  dif- 
ficult of  diagnosis  when  occurring  in  connection  with  inflammation 
of  the  middle  ear.  Deep-seated,  intense  pain  in  the  head,  for  a  time 
continual  and  then,  perhaps,  intermittent  for  a  day  or  more,  and  always 
increased  on  bending  the  head  forward,  may,  in  the  absence  of  severe 
symptoms  in  the  ear  itself  or  about  the  mastoidea,  be  regarded  as 
pathognomonic.  Yet  the  fact  remains  that  the  pains  of  aural  inflam- 
mation, if  present,  cannot  always  be  differentiated  from  the  above. 
Severe  headache,  vertigo,  staggering,  vaso-motor  disturbances,  as 
flushing,  bilateral  or  unilateral  sweating  about  the  head,  etc.,  are 
familiar  symptoms  in  severe  aural  disease,  even  where  a  favorable 
result  may  be  confidently  expected.  Prodromic  symptoms  by  means 
of  which  the  fatal  termination  of  any  particular  case  can  be  foretold 
are  generally  wanting.  We  are  thus  unable  to  distinguish  the  pain  of 
meningeal  irritation  and  neuralgic  headache  from  the  pains  of  peri- 
osteal inflammation  of  the  ear. 

A  case,  occurring  in  the  writer's  experience,  of  acute  purulent  in- 
flammation of  the  middle  ear  tract,  in  a  run-down  female  subject 
with  marked  neuropathic  symptoms,  occasioned  apprehensions  of  the 
existence  of  pachymeningitis,  and  an  eminent  consultant  was  inclined 
to  the  opinion  that  the  symptoms  pointed  to  tubercular  meningitis. 
Eecovery,  however,  took  place,  and  a  review  of  the  case  seemed  to 
justify  the  diagnosis  of  lepto-meningitis. 


OTITIS    MEDIA    SUPPURATIVA   ACUTA.  271 

Usually  when  the  more  pronounced  and  recognizable  symptoms  of 
pachymeningitis  and  cerebral  abscess  manifest  themselves^  as  convul- 
sions, p  aralysis  of  sotne  of  the  cranial  nerves,  coma  or  semi-coma, 
etc.,  the  case  has  already  passed  beyond  relief  by  surgical  treatment 
directed  to  the  ear. 

Threatened  brain  trouile,  so-called,  is  too  uncertain  a  condition 
upon  which  to  base  a  precautionary  operation  of  opening  up  the 
cellules  of  the  mastoid  through  its  cortex,  even  were  relief  to  be 
obtained  by  such  means. 

The  aid  of  the  ophthalmoscope  has  been  invoked  in  determining 
the  occurrence  of  optic  neuritis  or  choked  (congested)  disk  in  con- 
nection with  pachymeningitis  due  to  ear  disease,  but  this  condition, 
when  recognized,  can,  it  would  seem,  but  add  another  symptom  to 
others,  sufficiently  convincing  and  already  present. 

The  intermittent  pains  accompanying  intermittent  mastoid  abscess 
are  often  severe  enough  to  give  rise  to  apprehensions,  and  are  consid- 
ered by  some  authorities  as  an  indication  for  trephining  the  mastoid; 
h\  the  writer's  own  experience,  however,  they  have  not  been  found 
significant  of  special  danger. 

It  would  seem  that  the  pains  attending  a  descending  neuritis  of  the 
facial  nerve  in  its  passage  through  the  mastoid  might  be  misleading; 
the  author  has  seen  cases  of  this  kind  accompanying  acute  inflam- 
mation of  the  drum  of  the  ear  where  the  cellules  of  the  mastoid  were 
apparently  not  involved. 

The  appearance  of  the  external  auditory  canal  when  the  track  of  a 
tympano-mastoid  abscess  is  manifested  upon  its  posterior  or  superior 
wall  by  a  bulging,  purplish  sac,  may  be  mistaken  for  a  polypoid 
growth,  and  when  fungosities  make  their  appearance  after  the  sac 
ruptures  or  has  been  opened,  the  resemblance  is,  indeed,  misleading. 
Fungosities,  however,  are  seldom  abundant  unless  the  inner  wall  of 
the  canal  is  carious,  or  where  there  is  a  sinus  communicating  with  the 
mastoid  cellules.  < 

A  dissecting  abscess  may  reach  the  meatus  externus,  resembling 
the  swelling  caused  by  furuncular  or  diffuse  inflammation,  either  of 
which  may  close  the  lumen. 

Inflammation  of  the  subcutaneous  tissue  or  erysipelas  sometimes 
extends  into  the  external  auditory  canal  from  without,  but  does  not 
usually  give  rise  to  periostitis  externa;  when  occurring  along  with  in- 
flammation of  the  middle-ear  tract  a  diagnosis  is  not  so  easily  made. 

The  following  case  is  instructive  in  connection  with  the  question  of 
diagnosis: 

Acute  Purulent  Inflammation  of  the  Tympanic  Attic  and  Mastoid 


272  OTITIS    MEDIA    SUPPURATIVA    ACUTA. 

Antrum  caused  hy  the  use  of  the  Nasal  Douche  for  the  Relief  of  Rhi- 
nitis Sicca.     Pachymeningitis.     Cerebral  Congestion.     Death. 

The  patient,  38  3'ears  of  age,  Avas  employed  as  a  railroad  clerk. 
He  was  a  strong-looking  person  avIio  had  led  a  rather  exposed  outdoor 
life. 

For  the  relief  of  long-standing  suppurative  rhinitis  he  has  occa- 
sionally employed  the  nasal  douche,  using  a  solution  of  salt  in  warm 
water.  This  practice  has  been  followed  a  number  of  times  by  pain 
in  both  ears.  Five  weeks  ago,  after  using  the  douche  he  immediately 
experienced  pain  in  the  right  ear,  which  lasted  all  day,  and  a  few 
mornings  later  he  was  awakened  by  its  severity.  From  this  time  on 
the  pains  were  severe,  and  in  a  few  days  a  muco-sanguinolent  dis- 
charge appeared,  soon  succeeded  by  a  copious  flow  of  muco-purulent 
matter.  Although  suffering  greatly,  for  three  weeks  he  kept  on  at 
his  outdoor  work,  hoping  that  the  ear  would  get  well  without  treat- 
ment, but,  the  pain  becoming  unbearable,  he  finally  consulted  his 
family  physician.  He  was  advised  to  remain  indoors,  and  given 
morphine  freely,  but  the  pains  increased.  The  hypodermic  use  of 
morphine  was  now  resorted  to,  and  during  the  two  weeks  he  re- 
mained under  treatment  at  home  the  ear  was  constantly  poulticed 
and  syringed  three  or  four  times  a  day  Avith  carbolic  solution,  three 
drops  of  the  acid  to  the  ounce  of  water.  The  physician  and  his 
friends,  being  convinced  that  he  was  daily  getting  worse,  decided  to 
bring  him  to  New  York. 

Examination  at  the  New  York  Eye  and  Ear  Infirmary,  October 
9th,  1882.  The  patient  was  evidently  fatigued  by  the  Journey  of  75 
miles  on  the  rails.  He  had  the  appearance  of  having  suffered 
greatly;  was  anxious  and  depressed.  I^sually  of  a  ruddy  complexion, 
his  face  was  now  pale  and  the  malar  eminences  flushed.  The  eyes 
were  dull.  The  skin  was  humid,  and  he  was  closely  wrapped  in  heavy 
clothing,  though  the  day  was  not  cold.  He  said  he  felt  completely 
worn  out  from  loss  of  sleep  and  the  intense  suffering  he  had  experi- 
enced for  five  weeks.  From  being  courageous  he  had  become  exceed- 
ing neuropathic  and  timid,  and  was  specially  nervous  when  his  ear 
was  examined.  Laryngoscopic  examination  confirmed  the  existence 
of  ozaena.  The  teeth  and  gums  were  healthy.  The  appearance  of 
the  left  drum-head  showed  that  chronic  inflammation  had  long  been 
present. 

The  right  (affected)  ear  on  examination  showed  the  following:  The 
external  auditory  canal  was  large;  its  inner  end  was  red  and  consid- 
erably swollen;  near  the  drum-head  was  a  collection  of  dark  greenish, 
thick  pus.'  The  drum-head  was  red,  the  membrana  flaccida  fleshy 
looking  and  bulging.  In  front  of  the  short  process  of  the  malleus  is 
a  mass  of  pouting  granulation  tissue,  filling  a  perforation,  in  the 
centre  of  which  is  a  small  pulsating  light  reflex.  The  mastoid  process 
is  not  red  or  swollen,  nor  tender  to  the  touch.    There  is  intense  hemi- 

'  This  dark-greenish  purulent  matter  the  author  has  found  frequently  in 
the  subjects  of  ozaena — the  suppurative  action  in  the  middle  ear  tract  resem- 
bUng  that  in  the  naso-pharynx. 


OTITIS    MEDIA    SUPPURATIVA    ACUTA.  273 

crania  on  the  affected  side — localized  points  of  tenderness  over  the 
temple  and  nape  of  neck.     Hearing:  ordinary  voice  in  the  right  ear. 

The  attic  membrane  cleared  up  under  treatment;  the  membrana 
vibrans,  at  no  time  after  being  seen  much  affected,  was  incised  freely 
and  the  atrium  was  found  almost  normal — a  little  muciis  only  escap- 
ing. Valsalvan  experiment  showed  that  the  passage  from  the  throat 
to  the  drum  was  free  throughout.  The  perforation  in  the  membrana 
flaccida  healed  on  cessation  of  the  discharge,  and  the  patient  steadily 
improved,  but  up  to  the  time  of  his  departure  for  home  the  hemi- 
crania  continued  off  and  on. 

The  subsequent  history  and  report  of  post-mortem,  obtained  from 
his  physician,  was  to  the  effect  that,  after  his  return  home,  on 
November  1st,  the  periodical  attacks  of  frontal  and  vertex  pain 
became  more  frequent  and  severe,  without  any  discharge  from  the 
ear,  and,  coma  supervening,  the  patient  died  on  November  IStli. 
Upon  post-mortem  examination  the  meninges  and  veins  of  cortex 
were  found  to  be  markedly  congested.  The  temporal  bone  was  not 
examined. 

The  examination  of  the  case  at  the  Infirmary  left  the  impression 
that  the  severe  remittent  pains  might  be  neuralgic,  since  they  had 
continued  so  long  with  intervals  of  marked  improvement.  Were  the 
pains  those  of  pachymeningitis,  however,  this  symptom  indicated  its 
presence  from  the  outset,  and,  therefore,  drainage  having  been  good 
during  the  progress  of  the  case,  an  operation  on  the  ear  would  have 
been  of  no  avail. 

In  contrast  with  the  foregoing,  is  the  progress  of  a  case  occurring 
in  an  athlete,  a  man  of  good  constitution. 

Patient  contracted  an  acute  inflammation  of  the  tympanic  attic, 
accompanied  by  intense  pam,  in  consequence  of  taking  a  Eussian 
bath.  Excessive  zeal  in  treatment  had  converted  a  simple  case  into 
a  grave  one  before  he  came  to  the  Infirmary,  and  when  first  examined 
it  was  found  that  a  perforation  in  the  drum-head  which  admitted 
drainage  at  the  beginning,  had  closed  up,  and  a  dissecting  tympano- 
mastoid abscess  had  developed.  A  bulging,  fluctuating  tumor  pre- 
sented on  the  posterior  wall  of  the  external  auditory  canal.  A  free 
incision  was  made  into  this,  establishing  free  drainage.  Soon  after- 
wards, the  perforation  in  the  membrana  flaccida  reopening,  the  dis- 
charge began  to  escape  readily  through  the  tympanum.  This  opening 
now  quickly  assumed  a  nipple-like  form  as  a  markedly  favorable 
change  occurred;  the  sinus  on  the  posterior  wall  of  the  canal  closed, 
and  an  active  regressive  course  was  soon  followed  by  complete  cure. 

The  intense  pain  accompanying  the  periostitis  externa  in  this  case 
at  the  beginning,  together  with  an  interruption  of  drainage,  afforded 
an  indication  laid  down  by  some  writers  for  trephining  the  mastoid 
process. 

Prognosis.  In  cases  of  acute  purulent  inflammation  of  the  middle 
18 


2Y4:  OTITIS   MEDIA    SUPPURATIVA   ACUTA. 

ear  tract  where  a  non-meddlesome  plan  of  treatment  has  been  adopted 
from  the  beginning  the  prognosis  is  favorable,  both  as  regards  life 
and  preservation  of  hearing.  In  the  many  thousand  cases  of  ear  dis- 
ease coming  under  the  author's  observation  during  a  period  of  twenty 
years  of  special  practice,  of  those  seen  at  the  beginniug  no  fatal  case 
has  occurred;  of  the  cases  seen  after  severe  symptoms  had  developed, 
fourteen  cases  have  died—  some  of  them  so  long  after  the  aural  trouble 
had  abated  that  its  influence  as  a  factor  could  almost  exclude  them. 

In  very  young  children  it  seems  probable  that  the  acute  purulent 
process  is  much  more  likely  to  set  up  meningitis  than  in  older  persons, 
and  although  statistics  are  wanting  to  establish  the  prognosis  among 
this  class,  a  grave  or  fatal  issue  is  probably  much  more  frequent  than 
is  suspected. 

Treatment.  In  regard  to  the  more  simple  cases  of  acute  purulent 
inflammation,  where  the  process  does  not  extend  beyond  the  atrium 
of  the  tympanum,  but  little  need  be  said  here,  since  in  the  greater 
number  of  these,  as  in  otitis  media  acuta,  the  submucous  structures 
are  not  seriously  involved,  and  unless  the  patient's  condition  is  un- 
favorable, or  improper  treatment  has  been  the  means  of  aggravating 
the  case,  their  management  presents  no  difficulties. 

It  is  well,  therefore,  to  prevent  meddlesome  interference  and  en- 
join as  complete  rest  as  possible  for  the  first  few  days.  If  there  is 
free  secretion  of  sero-sanguinolent  or  muco-purulent  matter  with  ob- 
struction of  the  Eustachian  tube,  the  drum-head  is  usually  ruptured 
spontaneously,  but  if  found  distended  with  advancing  rather  than 
receding  inflammation,  it  is  good  practice  to  incise  and  give  vent  to 
secretions.  This  should  be  more  promptly  done  if  the  drum-head  be 
found  thickened,  either  as  a  result  of  cicatricial  transformation  or 
recent  engorgement  and  infiltration.  Discharge  having  been  estab- 
lished uninterruptedly,  so  far  as  otherwise  healtlw  subjects  are  con- 
cerned, an  expectant  course,  including  attention  to  keeping  the  ear 
clean,  is  advisable.  Cleansing  the  ear  may  be  accomplished  by  gentle 
syringing,  using  as  little  water,  well  warmed,  as  possible,  and  drying 
out  with  the  armed  cotton-wool  carrier.  A  weak  solution  of  boric 
acid  answers  well,  in  some  cases,  for  syringing.  When  catarrh  of  the 
entire  upper  air-tract  coexists  with  the  aural  catarrh,  minute  doses  of 
mercury  have  answered  well  in  the  author's  hands;  when  '* cricks" 
or  "malaria"  are  present,  small  doses  of  quinine  may  be  given,  and 
if  coated  tongue  with  gastric  disturbance  exist,  calx  sulphurata  is  in- 
dicated and  may  take  the  place  of  mercury.  The  pain  nearly  always 
present  in  some  degree  may  be  allayed  by  mild  nervines,  as  dilute 
tincture  of  pulsatilla,  aconite,  etc.     Hot  emollient  solutions  of  boric 


OTITIS   MEDIA    SUPPURATIVA    ACUTA.  275 

acid  in  cases  where  nasal  catarrh  is  present  may  be  employed  by 
gargling  or  sniffing  up  the  nose  cautiously. 

It  does  not  seem  good  practice  in  the  acute  stage,  or  when  healing 
of  perforations  is  taking  place,  to  forcibly  distend  the  membranous 
portion  of  the  drum  by  inflation. 

Under  the  treatment  outlined  above,  discharge  gradually  ceases  in 
the  majority  of  cases,  but  it  may  take  place  suddenly,  in  which  event 
a  cure  must  not  be  confounded  with  retention  of  discharge  from 
an  exacerbation  due  to  exposure  or  other  cause.  Where  pain  is  very 
severe,  large  doses  of  morphia  should  be  tentatively  given,  with  in- 
termission of  as  great  duration  as  possible,  since  consequent  reaction 
leaves  the  patient  much  depressed. 

The  so-called  dry  treatment  should  not  be  commenced  until  dis- 
charge diminishes,  and  when  perforations  begin  to  close  a  tolerably 
firm  incrustation  of  calendula  and  boracie  acid  powder,  when  it  does 
not  cause  irritation,  may  be  allowed  to  remain  as  a  support  to  the 
drum-head.  If  the  regressive  course  proves  to  be  sluggish,  the  instil- 
lation of  a  few  drops  of  calendula  will  hasten  the  healing  process. 

When  the  regressive  course  is  established,  outdoor  life  and  atten- 
tion to  business  may  be  resumed  to  a  degree  commensurate  with 
the  age  and  vigor  of  the  patient.  The  writer  has  frequently  seen 
cases  where  it  was  necessary  to  insist  on  the  resumption  of  bodily  ac- 
tivity. In  broken-down  subjects,  supporting  nutrition  from  the  be- 
ginning is  necessary. 

The  following  cases  are  of  interest,  representing,  as  they  do,  a  group 
of  cases  which  respond  readily  to  a  very  simple  course  of  treatment, 
by  which  various  instillations  and  vigorous  syringing,  so  often  in- 
jurious, are  avoided,  and  shown  to  be  quite  unnecessary,  a  cure  being 
brought  about,  and  pain  effectually  relieved,  by  simple  remedies  in- 
ternally administered. 

Otitis  media  puriilenta  acuta.  Marked  constitutional  disturbance, 
fever,  and  very  severe  pain.     Patient  discharged  cured  in  one  week. 

Feb.  llfh.  Female,  set.  8  years,  had  pain  in  left  ear,  with  discharge, 
two  years  ago.  She  attends  a  public  school,  where  she  is  constantly  ex- 
posed to  cold  draughts  of  air  from  the  windows,  which  are  opened  to 
admit  fresh  air  into  the  room  when  overheated  by  the  steam  radiator. 
Three  days  ago,  after  attending  school,  patient  complained  of  pain, 
tinnitus,  and  deafness  in  her  right  ear,  accompanied  by  marked  con- 
stitutional disturbance,  nausea,  vomiting,  and  fever.  Pain  also  in  the 
left  ear  this  morning.  On  examination,  both  drum-heads  were  found 
to  be  intensely  and  uniformly  hyperaemic  and  bulging;  no  perfora- 
tion, however,  being  visible.  Patient  could  hear  ordinary  voice  in 
both  ears.  She  was  restless  and  in  much  pain.  Temperature  102.2°. 
pulse  130.     The  treatment  consisted  of  the  tincture  of  aconite  and 


276  OTITIS    MEDIA    SUPPURATIVA    ACUTA. 

extract  of  belladonna,  given  at  frequent  intervals,  to  control  the  pain; 
calx  sulph.  (gr.  ^)  every  two  hours.  It  was  hoped  that  the  inflam- 
mation would  take  a  regressive  course,  and  paracentesis,  therefore, 
was  not  performed. 

12th.  The  right  membrane  has  been  ruptured,  the  pain  has  sub- 
sided, and  there  is  a  watery  discharge.  Aconite  and  belladonna  dis- 
continued. 

lAfh.  Patient  has  been  resting  well,  and  is  free  from  pain.  The 
discharge  from  right  ear  is  more  profuse,  and  of  a  purulent  char- 
acter. Canal  syringed,  and  powdered  boracic  acid  insufflated.  The 
left  canal  is  red  and  tender,  the  membrane  fleshy  and  bulging  slightly, 
but  no  perforation. 

15th.  Condition  improved,  and  discharge  diminished.  Boracic  acid 
insufflated.  Left  membrane  less  bulging,  and  injection  subsiding. 
Calx  sulph.  (gr.  -^\)  every  four  hours. 

18th.  No  discharge  from  right  ear;  canal  filled  with  dry  powder. 
The  left  membrane  is  clearing  up.     Calx  sulph.  discontinued. 

Acute  iiijiammation  of  attic  and  memhrana  flaccida.  Severe  pain, 
relieved  in  two  dags.     Discharged,  cured,  in  tivo  loeeks. 

Male,  aet.  8  years.  No  previous  ear  trouble.  For  past  five  weeks 
much  pain,  at  times  very  severe,  in  right  ear,  with  scanty  discharge. 
Loss  of  sleep  and  appetite.  On  examination,  free  purulent  discharge 
from  right  ear  is  found,  and  only  the  membrana  flaccida  of  drum- 
head is  seen,  the  same  being  fleshy  in  appearance  and  concealing  the 
upper  segment  of  the  membrane.  Hears  ordinary  voice  with  this  ear. 
Left  ear  normal. 

Aconite  and  belladonna  were  given  to  allay  pain.  Calx  sulph.,  at 
first  every  two  hours,  afterward  less  frequently.  Pain  subsided  in 
two  days,  and  discharge  ceased  in  eight.  Fourteen  days  later  the 
canal  dry,  and  drum-head  resuming  rapidly  its  normal  condition. 

Acute  inflammation  of  the  middle  ear.  Autophonia.  Pain  relieved 
in  three  days. 

Male,  aet.  27  years,  has  long  been  subject  to  earaches.  Head  catarrh 
not  marked.  Whilst  working  is  often  obliged  to  stand  knee-deep  in 
water.  For  the  past  week  pain  and  throbbing  in  left  ear,  accom- 
panied by  autophonous  phenomena.  Has  used  instillations  of  lauda- 
num, but  with  no  relief.  The  examination  shows  left  canal  filled 
with  muco-purulent  matter,  the  drum-head  fleshy  in  appearance,  with 
a  small  perforation  in  the  posterior  inferior  segment.  Hears  ordinary 
voice  with  affected  ear.     Right  ear  normal. 

Treatment  as  in  previous  cases.  Pain  and  discharge  had  ceased 
by  the  third  day.  The  dry  powder  in  canal  was  left  undisturbed  for 
a  time. 

The  gravity  of  complicated  cases  of  acute  purulent  inflammation, 
where  the  entire  middle-ear  tract  and  exterior  parts  are  generally 
more  or  less  involved,  is  important  enough  to  require  separate  and 
distinct  consideration  in  regard  to  their  treatment.  They  may  be 
divided  for  this  purpose  into  three  groups:     I.  Those  where  drainage 


OTITIS   MEDIA    SUPPURATIVA   ACUTA. 


277 


from  the  antrum  and  attic  is  impeded; 
II.  Those  where  a  tympano-mastoid  ab- 
scess has  formed;  III.  Those  where  a 
mastoid  abscess  exists. 

Attention  to  these  cases  will  first  be 
<3alled,  most  likely,  by  the  pain  attendant 
on  suppression  of  secretions.  Whether 
this  occurs  in  consequence  of  blocking 
up  the  outlets,  by  swollen  mucous  mem- 
brane, polypoid  masses,  sequestra  or 
general  periostitis,  and  inflammation  of 
the  subcutaneous  connective  tissue,  no 
time  should  be  lost  in  temporizing  and 
ineffectual  surgical  procedures.  In  vsuch 
cases  it  will  rarely  be  found  that  the 
atrium  of  the  tympanum  alone  is  chiefly 
affected,  since  drainage  from  this  region 
cannot  so  easily  be  arrested.  It  is  the 
invasion  of  the  tympanic  attic  and  mas- 
toid antrum  and  cellules  and  external 
periosteum  that  almost  invariably  gives 
rise  to  trouble  of  a  severe  character. 

/.    Where  drainage  from  the  attic  and 
antrum   through  the  tympanum  is  im- 
peded :  Directing  attention  in  these  cases 
first  to  the  drum-head,  we  shall  probably 
find  that  accumulations  in  the  attic  have 
finally  bulged  out  the  integument  com- 
posing the  membrana  flaccida,  increasing 
its   dimensions    at   the   expense   of   the 
superior  wall  of  the   external  auditory 
canal  above,  and  of  the  dermic  layer  of 
the  membrana  flaccida  below.     A  free 
incision,  carried  well  down  through  the 
■distended   tissues   of   the   canal   to   the 
bone,  and   continued   on  along   to   the 
margin   of  the  auditory  plate  and  well 
into  the  membrana  flaccida,  should  be 
made  without  delay.     The   author  has 
found  the  knife  shown  in  Fig.  43  well 
suited  to   this   operation.     Drainage    is 
best  secured  when  the  incision  is  carried 


Fio.  43.— Natural  size. 


278  OTITIS    MEDIA    SUPPURATIVA    ACUTA. 

freely  into  the  attic  where  one  or  the  other  of  the  passages,  situated  on 
either  side  of  the  handle  of  the  malleus,  affords  a  natural  outlet  for 
secretions  from  the  attic  to  the  atrium.  The  timely  interference 
by  means  of  this  operation  may  avert  the  more  severe  symptoms. 
Delay  in  these  cases,  where  periosteal  inflammation  is  extending  itself 
outwardly  from  the  tympanum,  favors  the  development  of  dissecting 
tympano- mastoid  abscess  which  may  eventually  involve  the  entire 
temporal  region — limited  only  by  the  outlines  of  the  temporal  fascia. 

II.  Where  a  tympanomastoid  abscess  has  formed :  Bulging  of  the 
tissues  in  these  cases  on  the  posterior  wall  of  the  external  auditory 
canal  should  not  be  mistaken  for  an  opening  from  the  cellules  of  the 
mastoid;  when  it  occurs  in  this  situation,  an  incision  should  be  made, 
even  though  an  opening  be  required  in  some  portion  of  the  peri-auri- 
cular region — and  when  a  counter-opening  is  thus  made  it  is  well  to 
introduce  some  strands  of  catgut  through  from  one  to  the  other. 
Although  in  mild  cases  of  periostitis  externa,  and  inflammation  of 
the  subcutaneous  connective  tissue,  reabsorption  sometimes  appears  to 
take  place,  it  is  a  safe  rule  to  liberate  purulent  matter  as  soon  as 
possible  after  its  detection. 

Nipple  like  formations  at  the  seat  of  perforations  in  the  drum-head 
are  liable  to  be  mistaken  for  polypi,  as  been  already  remarked,  and, 
indeed,  redundant  granulation  tissue  is  sometimes  present  in  the 
opening,  but  its  removal  is  seldom  advisable. 

The  following  cases  will  serve  to  further  illustrate  the  course  and 
treatment  of  severe  symptoms. 

Acute  Pui'ulent  Inflammation  of  the  Atticus  Tympanicus.  De- 
fective Drainage.  Formation  of  a  Dissecting  tympano  Mastoid 
Abscess.     Recovery. 

Mrs.  W.,  aged  38  years,  came  to  the  Kew  York  Eye  and  Ear  Infir- 
mary in  April,  1886. 

No  history  of  previous  aural  disease.  Six  weeks  ago  the  patient 
was  taken  with  pain  in  the  left  ear,  followed  by  a  discharge.  Three: 
weeks  ago  the  latter  ceased;  there  was  autoplionia,  and  deafness,  and 
headache  became  very  severe.  At  the  same  time  a  painful  swelling; 
was  noticed  over  the  mastoid  process.  No  vertigo  or  nausea.  Upon 
examination,  there  is  found  asymmetrical  prominence  of  the  left  auri- 
cle, and  the  whole  post-aural  region  of  that  side  is  swollen,  tense,  and 
fluctuating  in  one  spot.  The  posterior-superior  wall  of  the  external 
auditory  canal  is  so  much  detached  and  bulging  that  a  view  of  the 
deeper  parts  cannot  be  obtained.  The  meatus  contains  some  inspis- 
sated matter.     Patient  hears  ordinary  voice  in  affected  ear. 

It  was  decided  to  effect  drainage  by  an  incision  over  the  mastoid,, 
and  a  large  quantity  of  purulent  matter  was  thus  evacuated.  As  was 
suspected,  a  connection  between  the  cavity  of  abscess  and  the  atticus 


OTITIS   MEDIA    SUPTLRATIVA    ACUTA.  279 

tympanicas  existed,  being  detected  by  careful  exploration  with  the 
probe.  Three  days  later  the  subjective  symptoms  had  subsided,  and 
the  membrana  flaccida  and  the  membrana  vibrans  conld  now  be  seen. 
The  i^erforation  in  the  former  had  healed,  and  the  latter  was  found 
to  be  unaffected.  The  hearing  had  improved  to  low  voice.  In  five 
weeks  the  abscess  had  healed,  and  patient  was  discharged  cured. 

Acute  Purulent  Inflammation  of  tlie  Tympanic  Attic  and  Atrium. 
DissecHng  Tympano- Mastoid  Abscess.  Caries  of  the  Superior  Wall 
of  the  External  Auditory  Canal.     Recovery. 

Albert  J.,  aged  29  years,  came  to  the  New  York  Eye  and  Ear  In- 
firmary in  April,  1886.  He  indulges  freely  in  the  use  of  wine  and 
beer;  works  in  a  damp,  dark  room,  and  is  exposed  to  draughts  of  cold 
air  while  heated.  Two  months  ago  contracted  a  severe  cold  with 
pain  in  the  left  ear,  accompanied  by  deafness  and  autophonia.  Local 
applications  of  sweet  oil,  pieces  of  bacon,  and  the  like  were  made, 
and  he  continued  to  attend  to  his  work.  Two  weeks  ago  the  whole 
temporal  and  mastoid  regions  became  swollen  and  painful.  He  no- 
ticed no  aural  discharge. 

On  examination  of  the  left  ear,  the  superior-posterior  wall  of  the 
external  auditory  canal  was  found  so  completely  detached  that  a  view 
of  the  deeper  parts  could  not  be  obtained.  There  was  some  inspis- 
sated matter  present,  but  no  pus. 

The  left  temporal  and  mastoid  regions  were  uniformly  swollen  and 
tender,  but  no  fluctuation  could  be  obtained.  Patient  heard  loud 
voice  in  affected  ear.  He  had  hypertrophic  catarrh  of  the  upper  air 
tract,  and  carious  teeth. 

Pain  was  now  increasing,  and  the  patient  complained  of  vertigo. 

An  incision  was  made  through  the  membrana  flaccida,  and  out- 
wardly through  the  superior  wall  of  the  jcanal.  This  not  proving 
sufficient  to  evacuate  the  purulent  sac,  more  complete  drainage  was 
then  secured  by  counter-openings  made  in  the  temporal  and  mastoid 
regions,  and,  subsequently,  as  the  superior  wall  became  more  detached, 
its  most  dependent  part  was  also  opened.  Strands  of  catgut  were 
kept  for  a  time  in  the  sinus  extending  from  the  opening  in  front  of 
the  auricle  to  the  one  in  the  external  auditory  canal.  On  examina- 
tion of  the  parts  when  thus  opened  up,  the  upper  wall  of  the  bony 
portion  of  the  external  auditory  canal  was  found  to  be  denuded  and 
rough — the  place  being  marked  at  the  opening  in  the  canal  by  a  mass 
of  granulation  tissue.  The  operations  were  done  under  ether.  The 
patient  was  advised  to  rest,  and  calx  sulphurata  was  given.  Pain  was 
relieved  by  aconite.  Imrovement  was  rapid.  The  abscess  healed 
up,  suppurative  action  in  the  tympanum  ceased,  the  openings  cica- 
trized, and  on  the  thirtieth  day  patient  was  discharged  cured. 

III.  Where  a  mastoid  abscess  exists  :  From  the  foregoing  it  will  be 
seen  that  the  writer  favors  the  practice  of  keeping  open  an  outlet 
through  the  tympanum  into  the  external  auditory  canal,  for  the  pur- 
pose of   draining  the  middle  ear  tract,  rather  than  resorting  to  an 


280  OTITIS    MEDIA    SUPPURATIVA    ACUTA. 

operation  for  the  liberation  of  secretions  through  the  intact  cortex  of 
the  mastoid.  Of  course,  wliere  inflamed  structures  and  the  products 
of  the  inflammatory  process  give  rise  to  accumulations  in  the  mastoid 
and  antrum,  with  great  suffering  from  tension  through  inaccessible 
closure  of  the  passage  into  the  tympanum,  an  opening  through  the 
unaffected  cortex  of  the  mastoid  or  posterior  wall  of  the  external  au- 
ditory canal  would  be  indicated.  The  author  has  seldom  encountered 
a  case  of  this  kind.  Such  cases  must  be  rare,  when  the  previous 
treatment  has  been  proper. 

When,  however,  we  have  to  deal  with  urgent  symptoms,  it  will 
usually  be  found  that  some  local  disturbance  along  the  posterior  wall 
of  the  external  auditory  canal  or  over  the  cortex  of  the  mastoid  pro- 
cess indicates  an  effort  of  nature  to  liberate  pent-up  secretions. 
Where  the  mastoid  is  swollen,  and  a  regressive  process  does  not  look 
probable,  no  time  must  be  lost  in  making  an  incision  down  to  the 
bone,  unless  an  abscess  be  sooner  reached.  This  procedure  is  known 
as  Wilde^s  incision. 

The  lower  mastoid  cellules,  when  the  seat  of  purulent  inflam- 
mation, discharge  into  the  antrum  when  the  passage  is  unobstructed, 
otherwise  through  the  posterior  wall  of  the  external  auditory  canal  or 
the  cortex  of  the  mastoid  process.  From  his  own  observation,  the 
writer  believes  that  perforative  caries  takes  place  in  the  former  quite 
as  often  as  the  latter  situation.  In  external  periostitis,  the  posterior 
wall  of  the  canal  is,  perhaps,  more  frequently  affected  than  the  cortex 
of  the  mastoid  process.  •  Were  there  any  indications  to  guide  the 
surgeon  in  the  detection  of  pent-up  secretions  in  the  cellules  of  the 
mastoid  before  a  sinus  had  announced  the  fact,  the  author  should  not 
hesitate  to  perforate  healthy  tissues  in  order  to  relieve  the  patient; 
but  he  is  aware  of  no  such  indications. 

Where  the  inflammatory  process,  either  an  internal  or  external 
periostitis,  or  both,  has  caused  the  destruction  of  the  cortex  of  the 
mastoid,  the  sinus  should,-  of  course,  be  kept  open  and  enlarged  by 
cutting  or  chiselling  if  necessary,  remembering  that  the  cranial  fossa 
is  only  separated  from  the  cellular  structure  by  a  more  or  less  thin 
shell  of  bone.  Special  efforts  need  not  always  be  made  to  maintain 
the  opening  after  drainage  through  the  natural  channel  has  been 
established.  Usually  the  cortical  opening  quickly  closes  spontane- 
ously in  a  large  number  of  cases  so  soon  as  drainage  from  the  tympa- 
num becomes  efficient. 

The  urgency  of  the  symptoms  in  certain  cases,  in  view  of  a  possible 
fatal  result,  has  induced  some  authorities,  however,  to  recommend 


OTITIS   MEDIA    SUPPURATIVA    ACUTA.  281 

trephining  the  mastoid,  and  the  following  indications  have  been  laid 
down  for  its  performance  by  Schwartze:' 

1.  "  In  cases  of  acute  inflammation  of  the  mastoid  process  with 
retention  of  pus  in  its  cells,  when  tlie  oedematous  swelling,  pain,  and 
fever  do  not  subside  after  treatment  with  ice  or  Wilde's  incision.  In 
cases  of  secondary  inflammation  of  the  mastoid  process,  every  cause 
for  the  retention  of  pus  in  the  auditory  canal  and  in  the  tympanum 
should  be  first  removed.  In  this  manner  alone  appearances  of  in- 
flammation of  the  mastoid  not  seldom  take  on  a  regressive  course, 
even  where  they  are  accompanied  by  quite  threatening  symptoms 
(high  fever,  continual  pains  in  the  head  and  neck,  caput  obstipum, 
and  infiltration  of  deep-lying  cervical  tissues);  but  this  improvement 
is,  in  most  cases,  only  temporary,  and  in  the  course  of  weeks  or 
months  a  change  for  the  worse  takes  place,  which  finally  renders  the 
operation  necessai-y." 

2.  "In  cases  of  chronic  inflammation  with  intermittent  swelling  of 
the  mastoid,  or  where  abscesses,  resp.  fistulous  openings  in  the  skin 
have  already  formed  over  the  same,  with  abscesses  in  the  lateral 
region  of  the  neck,  in  the  auditory  canal  or  in  the  direction  of  the 
pharynx,  even  if  no  immediate  symptoms  threateni)ig  life  are  present." 

3.  ''In  cases  of  externally  healthy  mastoid,  where  there  is  retention 
of  pus  or  tlie  formation  of  a  cholesteatoma  in  the  middle  ear,  and 
which  may  not  be  removed  through  the  natural  channels,  as  soon  as 
symptoms  arise  which  render  the  appearance  of  a  dangerous  complica- 
tion probable." 

4.  "In  cases  where  the  mastoid  process  (externally  healthy  and 
without  retention  of  pus  in  the  middle  ear)  is  the  seat  and  starting- 
point  of  continual  and  unendurable  pain,  for  the  relief  of  which  all 
other  means  have  failed.     (Bone  neuralgia)."' 

5.  "As  a  prophylactic  operation  against  lethal  conditions  conse- 
quent to  incurable  putrid  discharge  from  the  middle  ear,  where  no 
appearances  of  inflammation  in  the  mastoid  and  no  otlier  symptoms 
of  the  retention  of  pus  in  the  middle  ear  (pain,  fever)  exist,  other  than 
the  intense  penetrating  foetor  of  the  purulent  discharge,  in  spite  of 
the  most  careful  cleansing  and  disinfection  through  the  auditory 
canal  and  Eustachian  tube." 

Schwartze  says,  furthermore,  that  the  chief  sources  of  danger  from 
the  operation  are  profuse  hemorrhage  from  the  bone,  exposure  of 
the  middle  fossa  of  the  skull  or  of  the  transverse  sinus,  and  septic 
infection. 

The  same  author  states  also  that  "aside  from  the  contra-indications 
applicable  to  all  larger  operations  (tuberculosis,  when  far  progressed, 
diabetes,  etc.),  the  operative  opening  of  the  mastoid  has  a  special 
contra-indication,  namely,  where  there  are  positive  indications  that 
meningitis  or  cerebral  abscess  already  exist." 

'  Chirurgische  Krankheiten  des  Ohres.    Stuttgart,  1885,  p.  834  et  seq. 


282  OTITIS   MEDIA    SUPPURATIVA    ACUTA. 

The  "indications"  thus  laid  down  by  Schwartze  do  not  seem  to  the 
writer  suflficient  to  warrant  a  frequent  resort  to  the  operation.  To 
consider  them  somewhat  in  detail. 

Of  the  first  indication,  it  cannot  be  admitted  that  '•' oedematous 
swelling,  pain,  and  fever"  are  pathognomonic  of  ''acute  inflamma- 
tion of  the  mastoid  process  with  retention  of  pus  in  its  cells/'  nor 
should  the  author  rely  on  an  incision  over  the  mastoid,  or  ice  appli- 
cations alone,  to  relieve  inflammation  of  the  cellules,  even  though 
the  above  symptoms  were  accepted  as  pathognomonic  of  this  condi- 
tion. 

As  regards  the  second  indication,  "  intermittent  swelling,"  it  is 
of  frequent  occurrence  in  acute  cases  where  drainage  from  the  tym- 
panum is  interrupted  by  the  closure  of  a  sinus  from  the  cellules  of 
the  mastoid,  or  by  a  clogging  up  of  the  trSct  of  a  dissecting  tympano- 
mastoid process.     It  does  not  "threaten  life." 

The  third  and  fourth  indications  may  be  taken  as  guarded  opin- 
ions in  respect  to  contingencies  the  importance  of  which  are  largely 
a  matter  of  individual  judgment. 

In  respect  to  the  fifth  indication  of  Schwartze,  quoted  above,  one 
can  but  consider  that  an  operation  is  recommended  simply  as  a  dernier 
ressort. 

The  views  of  Schwartze,  as  found  in  the  literature  of  this  country,, 
can  scarcely  be  said  to  fairly  represent  the  opinions  cited  above;  as 
thus  taken  from  his  recent  writings  there  is  little  that  cannot  be 
heartily  commended.  It  has  seemed  to  the  writer,  however,  that 
those  who  have  been  most  prominent  in  professing  to  follow  the  prac- 
tice of  Schwartze  in  this  coiuitry,  if  guided  correctly  by  his  early 
teachings,  do  not  keep  pace  with  the  conclusions  to  be  drawn  from 
his  later  experience. 

There  can  be  no  justification  for  the  haste  to  trephine  or  chisel 
into  healthy  mastoid  tissues,  as  lately  evinced  in  this  country.  Thus 
advantage  to  the  patient  is  said  to  result  from  carrying  a  canal  from 
the  mastoid  cortex  into  sound  bone,  especially  when  the  latter  is  hy- 
pertrophied  from  previous  inflammation  of  the  cellules.  The  writer 
is  convinced  that  nothing  is  gained  by  such  exploits,  but  that,  on  the 
contrary,  they  are  to  be  deprecated.  One  of  the  cases,  briefly  de- 
scribed on  a  previous  page,  presented  almost,  if  indeed  not  all,  of  the 
symptoms  laid  down  by  some  writers  for  opening  the  mastoid;  for,  in 
addition  to  other  symptoms  mentioned  in  the  report,  there  was  inter- 
mittent swelling  over  the  mastoid,  intense  vertigo,  nausea,  and  vom- 
iting, with  elevation  of  temperature.  All  of  these  symptoms,  how- 
ever, disappeared  on  the  establishment  of  drainage  by  a  free  opening- 


OTITIS   MEDIA    SUPPDRATIVA   ACUTA.  283 

into  the  posterior  wall  of  the  external  auditory  canal,  where  the  point- 
ing was  prominent. 

Where  periostitis  interna  is  suspected  of  having  reached  the  cel- 
lules, it  has  been  the  author's  own  experience  that  drainage  for  the 
entire  middle  ear  tract  can  best  be  maintained  through  the  natural 
channel  of  the  tympanum,  and  following  out  this  course  in  practice 
has  never  been  to  his  knowledge  attended  with  fatal  results.  But 
should  the  difficulties  attending  this  operation  be  urged  against  its 
adoption,  it  may  be  said  in  reply  that  no  safe  guide  indicating  the 
employment  of  the  trephine,  either  for  the  prevention  or  for  the  re- 
lief of  pachymeningitis,  is  known.  Trephining  into  the  mastoid  for 
threatened  pachymeningitis  in  this  manner  could  only  be  regarded  as 
a  warrantable  surgical  procedure  at  an  early  stage  when,  unfortu- 
nately, no  sure  pathognomonic  symptoms  are  recognizable. 

One  cannot  but  regard  the  expressions '' threaten  life,"  "  brain 
symptoms,"  "  symptoms  of  cerebral  irritation,"  and  the  like,  too  fre- 
quently used  in  this  connection,  as  untenable  assumptions,  and  mis- 
leading, and  which,  when  accepted  too  confidently,  tend  to  increase 
the  importance  of  misconceived  indications  rather  than  the  establish- 
ment of  sound  surgical  principles. 

It  seems  by  no  means  improbable  that  the  course  of  many  cases  of 
purulent  inflammation,  Avith  symptoms  that  "  threaten  life,"  alleged 
to  have  been  cured  by  the  intervention  of  an  operation  of  trephining, 
would  have  been  equally  and  very  probably  much  more  satisfactory 
without  this  procedure.  The  patient's  testimony  as  to  relief  in  these 
cases  must,  as  often  happens  after  seemingly  important  procedures, 
frequently  be  taken  with  some  allowance;  it  is  often  of  no  value 
whatever;  and,  moreover,  the  advantages  of  the  preliminary  incision 
through  the  integument,  where  indicated,  should  be  considered. 

The  results  of  this  operation  (trephining)  are  sometimes  by  no 
means  as  harmless  as  its  easy  performance  would  indicate,  for  fatal 
results  are  not  at  all  uncommon,  and  we  may  in  any  case  convert  a 
simple  catarrhal  inflammation  of  the  pneumatic  cells  into  a  most' 
troublesome  ostitis.  Inasmuch  as  the  danger  of  cerebral  complica- 
tions does  not  necessarily  arise  from  the  pressure  of  pent-up  secre- 
tions, but  rather  from  transmission  by  contiguity,  anastomosis  of 
vessels,  etc.,  trephining  cannot  always,  even  when  pus  is  liberated, 
be  relied  on  to  prevent  their  occurrence,  however  early  it  may  be 
performed.  In  acute  otitis  media  the  mastoid  region  may  be  greatly 
swollen  externally;  there  may  be  much  pain,  and  yet  an  extension  of 
the  middle  ear  inflammation  to  the  dura  mater  may  take  place,  while 
the  mastoid    cells   remain    comparatively  free   of  any  complication; 


284  OTITIS   MEDIA    SUPPUKATIYA   ACUTA. 

under  such  circumstances,  if  pain  and  swelling  of  the  peri-mastoid 
tissues  were  to  be  taken  as  indicating  the  necessity  for  trephining  the 
mastoid,  we  should  then  have,  were  the  operation  performed,  a  serious 
wound  of  this  bone  added  to  the  other  grave  conditions  that  attend 
inflammation  of  the  meninges  of  the  brain.  The  author  cannot  but 
believe,  viewing  the  matter  in  this  light,  that  the  operation  has  been 
needlessly  performed  in  a  great  many  instances.  It  is  stated  by  most 
authorities  that  this  operation  is  usually  followed  by  the  relief  of  the 
urgent  and  threatening  symptoms,  together  with  the  pain.  It  is  dif- 
ficult to  understand  how  this  can  be.  especially  in  cases  where  cere- 
bral disease  arises  from  direct  transmission  from  the  middle  ear  and 
the  communicating  mastoid  antrum,  or  from  previous  absorption 
from  the  mastoid  itself;  and  when  neuralgic  pains  have  their  origin 
in  other  parts,  relief  from  this  operation  is  likewise  improbable. 

Intense  inflammation  of  the  tissues  over  the  mastoid  process,  with 
redness  and  swelling,  in  the  course  of  acute  inflammation  of  the 
mucous  tract  of  the  ear,  does  not,  however  great  the  accompanying 
pain,  always  require  active  interference  ;  the  symptoms  very  often 
disappear  spontaneously — especially  in  young  children  they  frequently 
disappear  as  quickly  as  they  come.  But  where  such  symptoms  persist, 
a  free  incision  carried  down  to  the  bone  will  often  be  advisable  even 
before  fluctuation  is  detected. 

Meningitis  may  suddenly  develop  in  cases  where  the  aural  symp- 
toms have  not  been  severe  or  alarming;  on  the  other  hand,  the  most 
urgent  muco-periosteal  inflammation  of  the  middle  ear  tract  may 
exist,  with  so-called  brain  symptoms,  without  brain  lesion. 

The  success  so  far  attained  in  affording  drainage  through  tlie 
tympanum  in  purulent  inflammation  of  the  middle  ear  tract,  and  the 
doubtful  beneflt  to  be  derived  from  an  exploration  into  osseous  tissues 
of  the  mastoid  process,  when  possibly  healthy,  have  deterred  the 
writer  as  yet  from  the  latter  procedure. 

It  should  not  be  forgotten,  in  observing  the  progress  of  caries  of 
the  temporal  bone,  that  it  differs  from  that  of  any  other  bone,  since 
it  has  a  large  mucus-lined  cavity,  the  secretion  from  which  very 
much  increases  the  difficulty  of  treatment.  It  has  the  advantage, 
liowever,  over  other  bones  during  inflammation,  of  possessing  a  nu- 
trient periosteal  membrane,  lining  it  within,  whilst  covered  by  the 
periosteum  without,  thus  insuring  rapid  restoration  under  favoring 
conditions. 


OTITIS    MEDIA    SUPPURATIVA    CHRONICA. 


285 


OTITIS   MEDIA   SUPPURATIVA   CHRONICA. 

The  form  of  disease  to  be  described  under  this  name  is  a  sequence 
of  unchecked  or  badly  managed  acute  inflammation  of  the  middle  ear, 
especially  in  those  persons  whose  habits  or  general  condition  tend  to 
favor  chronicity.  This  result^  indeed,  is  not  an  unusual  occurrence 
in  spite  of  the  best  possible  treatment. 

Etiology.  In  a  large  number  of  patients  seen,  the  disease  has  ex- 
isted for  many  years,  having  begun  in  infancy. 

The  foUovring  table  exhibits  the  ages  and  sex  of  over  twelve  hun- 
dred of  the  author's  cases: 


AGE. 

Under  1  year  of  age. . . . 
Between  1  and  2  years. . , 
Between  2  and  3  years  . . 
Between  3  and  4  years. . , 
Between  4  and  5  years. . . 
Between  5  and  10  years. . 
Between  10  and  20  years 
Between  20  and  30  years 
Between  30  and  40  years , 
Between  40  and  50  years. 
Between  50  and  60  years 
Between  60  and  70  years 
Between  70  and  80  years. 

Total 


MALES. 

FEMALES. 

8 

7 

18 

7 

16 

22 

16 

26 

8 

29 

83 

119 

211 

165 

155 

82 

80 

46 

40 

33 

32 

14 

10 

1 

2 

679 

551 

15 

25 

38 

42 

37 

202 

376 

237 

126 

73 

46 

11 

2 


1,230 


Of  the  patients  under  one  year  of  age  the  youngest  was  two  months, 
the  eldest  eleven  months. 

Among  children  the  unfavorable  influence  of  a  depraved  constitu- 
tion, favoring  the  continuance  of  hypertrophic  rhinitis,  enlarged  ton- 
sils, and  disturbances  of  dentition,  was  shown  in  the  nature  of  the 
aural  trouble.  With  profuse  secretion  of  muco-purulent  matter  in 
the  ear,  discharge  from  the  nose  and  eyes,  and  in  numerous  instances, 
eczema  of  the  face  and  head  frequently  occurred.  Examination  of 
the  fundus  of  the  ear  showed  more  or  less  destruction  of  the  drum- 
head, whilst  the  tjmpanum  in  the  more  active  cases  was  usually  found 
filled  with  exuberant  granulation  tissue  and  sero-sangu indent  or 
mucopurulent  matter  in  varying  relations.  The  discharges  were  very 
often  offensive  smelling,  and  gave  rise  to  an  ulcerated  condition  of 
the  external  auditory  canal  over  which  they  flowed.  The  course  of 
the  diseaes  in  these  broken-down  subjects  generally  manifested  but 
little  tendency  towards  spontaneous  improvement  until  treatment  had 


286  OTITIS   MEDIA   SUPPURATIVA   CHRONICA. 

brought  about  a  favorable  change  in  the  general  condition,  especially 
of  the  naso-pharynx. 

In  but  few  cases  of  protracted  otorrhcea  will  it  be  found  that  either 
consumption,  syphilis,  scrofula,  or  some  dyscrasia  has  not  its  influ- 
ence, or  that  reflex  irritation  or  vaso-motor  influences  have  failed  to 
prolong  the  trouble. 

The  alleged  origin  of  a  large  number  of  instances  of  otitis  media 
purulenta  chronica  in  scarlet-fever  or  measles  is  rather  misleading, 
though  we  cannot  always  verify  our  suspicions  in  this  regard.  It 
seems  to  the  writer,  however,  that  many  of  the  cases  alleged  to  be  the 
sequelae  of  the  diseases  mentioned  are  due  to  other  causation,  the 
chronicity  depending  not  so  much  on  any  special  influence  imparted 
by  the  exanthemata  as  on  the  unfavorable  condition  of  the  patients 
themselves.  There  can  be  no  doubt  of  the  fact,  nevertheless,  that 
many  of  the  most  destructive  aural  inflammations  arise  during  the 
course  of  the  exanthemata  (Chapter  V.). 

Objective  Symptoms.  Since  purulency  has  usually  been  of  long 
standing  before  we  are  called  upon  for  aid,  the  ear  drum  will  be  found 
to  have  undergone  greater  or  lesser  changes  in  most  cases. 

The  results  of  destructive  inflammation  of  the  drum  embrace  loss 
of  substance  of  the  drum-head  on  the  one  hand  and  cicatricial  repro- 
duction on  the  other  ;  displacement  and  caries  of  the  ossicles,  and  an 
almost  endless  variety  of  deformities  of  the  transmitting  mechanism, 
in  consequence  of  the  pathological  changes  due  to  destructive  in- 
flammation. As  a  result  of  suppurative  inflammation  of  the  atrium, 
one  or  more  (usually  one  only)  perforations  maybe  observed  of  greater 
or  less  size  ;  whilst  more  or  less  granulation  tissue  will  be  found  on 
its  walls.  Sometimes  polypoid  growths  are  also  present.  The  more 
important  cases,  however,  are  those  in  which  the  attic  has  been  in- 
volved, with  one  or  more  sinuses  leading  through  the  membrana  flac- 
cida  into  this  cavity  ;  one  only  as  a  rule,  but  sometimes  one  in  front 
and  one  behind  the  hammer,  a  posterior  opening  being  most  frequent. 
Very  often  cases  are  encountered  where  the  membrana  vibrans  is  ab- 
sent, a  fringe-like  border  above  being  left,  comprising  the  membrana 
flaccida ;  in  such  cases  the  ossicles  may  remain  in  situ  though  usually 
more  or  less  diseased.  Sometimes  the  malleus,  or  its  handle,  or  the 
incus  is  absent,  and  frequently  both  of  these  ossicles  are  missing. 
The  incudo-stapedial  articulation  may  or  may  not  be  found  remaining 
even  where  all  three  of  the  ossicles  are  present. 

The  malleus  and  incus  are  often  adherent  to  each  other  in  varying 
degrees  of  attachment ;  and  the  head  of  the  malleus  becomes  fre- 
quently attached  to  the  tegmen  tympani. 


OTITIS    MEDIA    SUPPURATIVA    CHRONICA.  287 

In  a  large  number  of  cases,  however,  the  inflammatory  process  will 
be  found  to  have  extended  backwards  along  the  petro-mastoid  canal 
into  the  mastoid  antrum  and  cellules  (see  Fig.  45),  and  even  to 
those  cells  lying  in  the  tegmen  or  above  the  external  auditory  canal. 
In  many  instances  where  the  drum-head  has  been  destroyed,  to  a 
greater  or  less  extent,  and  the  ossicles  are  missing,  on  looking  into 
the  ear,  a  large  cavern,  embracing  the  tympanum,  mastoid  antrum, 
and  some  of  the  cellules  is  seen  and  which  remains  during  life.  This 
pathological  cavity  in  certain  cases  opens  outwardly  by  a  larger  or 
smaller  canal  through  the  mastoid  cortex  behind  the  auricle  ;  the 
cavity  is  usually  lined,  when  a  cure  has  taken  place,  by  a  white, 
polished  surface  of  uncovered  bone  or  cicatricial  tissue.  In  some 
cases,  however,  we  shall  find  the  mucous  membrane,  especially  of 
the  antrum,  infiltrated  and  filling  these  cavities,  assuming  a  gela- 
tinous character.  "Where  the  mastoid  cellules  have  been  destroyed 
by  inflammation,  especially  in  youth,  it  is  not  uncommon  to  after- 
wards find  a  cicatrix  behind  the  auricle  in  place  of  the  open  sinus  just 
mentioned.  When  the  inner  tympanic  wall  also  gives  way  to  caries 
and  necrosis,  the  labyrinth  is  included  in  these  caverns,  which  usually 
contain  more  or  less  desquamative  material,  cerumen,  and  other 
debris.  Occasionally  the  margin  of  the  auditory  plate,  forming  the 
upper  portion  of  the  tympanic  ring,  is  also  missing,  and  more  rarely, 
in  children,  the  entire  auditory  plate  is  detached.  When  to  this  is 
added  the  destruction  of  a  portion  of  the  tympanic  process,  the  de- 
formity is,  of  course,  much  increased.  The  thickened  remnants  of 
the  drum-head  are  often  found  retracted  and  adherent  to  the  inner 
wall  of  the  tympanum,  thereby  partially  occluding  the  outlets  from 
the  attic  and  antrum.  In  these  cases  polypoid  masses  are  frequently 
met  with,  sproutingfrom  the  antrum  or  attic,  and  protruding  through 
the  perforation  in  the  membrana  flaccida,  or  dipping  down  behind  the 
membrana  tympani  into  the  atrium.  A  deep  sinus  is  present  in  some 
cases  of  chronic  inflammation  of  the  middle  ear,  containing  often 
either  pultaceous  matter  or  inspissated  pus,  sometimes  polypoid  tissue 
or  epithelial  crusts,  and  leading  through  the  membrana  flaccida  or 
inner  extremity  of  the  external  auditory  canal  up  into  the  attic,  and 
in  some  cases  from  thence  into  the  antrum. 

Von  Troeltsch,  who  observed  these  sinuses  twenty-five  years  ago, 
believed  that  they  were  due  to  perforation  of  the  roof  of  the  external 
auditory  canal  in  cases  where  the  cellules,  sometimes  extending  over 
this  region,  were  the  seat  of  disease.  That  their  origin  may  be  thus 
explained  in  some  cases  the  writer  has  no  doubt,  but  more  frequently 
they  depend  on  perforation  of  the  membrana  flaccida.     Subsequently 


288  OTITIS    MEDIA    SUPPURATIVA    CHRONICA. 

to  Vou  Troeltsch's  observatious  this  condition  of  things  attracted  the 
attention  of  others ;  several  eases  came  under  the  observation  of  Dr.  J. 
0.  Green/  who  regarded  the  trouble  as  beginning  with  a  catarrhal 
inflammation,  which  afterwards  became  purulent,  involving  to  a 
greater  or  less  extent  the  entire  tympanum,  "but,"  he  says,  *'the 
mucus  secreted  among  the  ligaments  and  other  structures  in  the 
upper  part  of  the  tympanum  is  unable  to  gravitate  to  the  floor  of  the 
cavity  on  account  of  its  confined  position." 

Both  Drs.  C.  H.  Burnett  and  C.  J.  Blake  reported  cases  also.* 
Subsequently  the  latter  writer  drew  attention  to  acute  invasions  of 
the  upper  part  of  the  tympanum,'  observing  that  the  tympanum  be- 
comes inflamed  during  the  first  few  hours,  at  the  furthest  in  twenty- 
four  hours,  and,  that  when  the  raembrana  tympani  was  opened,  it 
gave  vent  to  a  copious  serous  discharge.  He  seems  scarcely  to  have 
considered  the  affection  as  rising  altogether  independently  of  the 
atrium  of  the  tympanum,  a  view  also  apparently  accepted  by  other 
writers. 

Discharge.  This  is  more  or  less  profuse  according  to  the  extent  of 
destructive  inflammation  ;  exposure  of  bone,  caries  of  the  drum 
generally,  favors  the  development  of  granulation  tissue,  and  upon 
this  and  the  action  of  the  mucous  surface  depends  largely  the  quality 
and  character  of  the  secretions  composing  the  otorrhoea.  With  a  free 
and  bad  smelling  discharge,  especially  in  young  patients,  we  often 
find  the  canal  ulcerated,  swollen,  and  very  tender,  as  in  acute  purulent 
inflammation  of  the  middle  ear.  The  itching  consequent  on  this  con- 
dition sometimes  induces  scratching  and  picking  of  the  parts  by  the 
patient,  which,  of  course,  goes  to  increase  and  exaggerate  the  irrita- 
tion. 

In  some  cases  of  protracted  inflammation,  the  secretion  is  almost 
exclusively  purulent,  and  becomes  inspissated,  sometimes  tough  and 
pultaceous;  of  such  material  are  cholesteatomatous  masses  in  part 
composed. 

Secretions  are  sometimes  exceedingly  offensive;  this  is  due,  in  a 
great  measure,  to  neglect  of  cleanliness,  especially  in  hot  weather, 
and  in  children  over-proliferation  is  most  common  and  marked.  The 
offensiveness  of  the  discharge  is  often  increased  from  its  being  pent 
up  in  the  tympanum,  owing  to  the  presence  of  polypi.  For  a  descrip- 
tion of  aural  polypi  the  reader  may  consult  Chapter  XIV. 

'  An  unusual  variety  of  purulent  inflammation  of  the  tympanum,    Boston 
Medical  and  Surgical  Journal,  March  6th,  1874. 
^  Meeting  of  the  American  Otological  Society,  1874, 
2  American  Journal  of  Otology,  April,  1882. 


OTITIS   MEDIA    SUPPURATIVA   CHRONICA. 

Subjective  Symptoms  and  Course.  Pain  is  an  occasional  symptom 
often  due  to  reflected  irritation  and  manifesting  itself  as  neuralgia 
about  the  ear  and  temporal  region,  sometimes  with  more  or  less  head- 
ache or  hemicrania. 

Autophonia  is  experienced,  in  some  cases,  especially  where  a  consid- 
erable portion  of  the  drum-head  remains. 

Noises  in  the  ear  are  nearly  always  present,  but  they  are  not  so 
common  as  in  acute  processes.  Usually  it  is  only  where  an  acute  ex- 
acerbation sets  in,  as  an  accompaniment  to  head  colds,  that  pain  and 
tinnitus  are  of  a  nature  to  cause  any  apprehension  or  trouble  to  the 
patient  (see  Chapter  XVI.). 

Deafness  is,  however,  the  most  unvarying  and  pronounced  feature 
of  the  trouble,  varying  according  to  the  defectiveness  of  the  trans- 
mitting mechanism  or  injury  of  the  deeper  lying  structures  in  whicli 
the  auditory  nerve  is  distributed. 

Vertiginous  phenomena  are  frequent,  especially  in  the  run-down 
class  of  cases,  in  whom  purulency  is  so  often  found  to  exist.  This 
feature  is  particularly  manifest  in  operative  procedures,  or  in  probing 
or  syringing  the  ear. 

Eeflex  phenomena.  The  aural  reflex  is  most  significant,  and  was 
observed  by  the  very  earliest  writers  on  the  ear.  It  will  be  found  to 
exist  in  some  degree  in  nearly  every  case  of  aural  disease,  but  more 
especially  in  the  class  under  consideration  here,  its  most  frequent 
symptom  being  what  is  usually  called  "  ear  cough.^'  The  latter  phe- 
nomenon occurs  in  numerous  cases  on  the  introduction  of  a  speculum 
or  the  manipulations  to  which  the  ear  is  more  or  less  subjected  during 
treatment.  Other  reflex  phenomena  arising  from  the  same  causes 
often  manifest  themselves  in  almost  every  region  of  the  mucous 
lining  of  the  upper  air-tract.  As  examples  of  such  may  be  mentioned 
the  sensation  of  tickling  in  the  throat,  an  irresistible  desire  to  swal- 
low, tingling  in  the  tongue,  sneezing,  and  often  vomiting,  experienced 
by  different  individuals  during  the  progress  of  aural  examinations  and 
manipulations. 

A  chronic  purulent  process  often  exists  from  infancy  to  old  age 
without  receiving  any  attention  or  in  any  way  alarming  the  patient. 
The  tolerance  of  .a  "running  ear"  with  its  attendant  symptoms  is 
largely  a  social  question  unless,  indeed,  pain  is  severe.  This  may  be 
plainly  seen  in  contrasting  private  practice  with  hospital  experience; 
in  the  latter,  cases  are  constantly  met  with  that  have  existed  a  long 
time  without  treatment.  Where  purulent  secretion  is  slight,  it  often 
dries  up  in  the  drum  or  canal  as  rapidly  as  formed;  when  masses  of 
inspissated  matter  thus  collect,  they  are  picked  out  by  the  patient  or 
19 


290 


OTITIS   MEDIA    SUPPUKATIVA    CHRONICA. 


escape  of  themselves,  and  are  almost  indistinguishable  from  hardened 
wax. 

In  certain  instances,  however,  where,  as  mentioned  before,  a  greater 
or  less  area  of  mucous  membrane  remains  in  a  pathological  condition, 
the  secretion  of  muco-purulent  matter  from  this  surface  continues, 
and  is  sometimes  so  abundant  that  tissues  which  have  already  under- 
gone cicatricial  transformation  again  become  unhealthy. 

Sometimes  this  swollen  state  of  the  mucous  membrane  of  the  deeper 
portions  of  the  middle  ear  tract  remains  for  years  without  causing 
any  symptoms;  but  should  caries  of  the  bone  occur,  urgent  symptoms 
may  arise  from  impeded  drainage. 

THE   OCCUKRENCE   OF   SEVERE   OR   GRAVE    SYMPTOMS    IN    THE    COURSE 
OF    CHRONIC    PURULENT    OTITIS    MEDIA. 

The  writer  has  above  alluded  to  the  fact  that,  under  certain  patho- 
logical conditions,  drainage  of  secretions  from  the  attic  may  be  much 
interfered  with,  and,  in  the  event  of  an  acute  exacerbation  of  the 
chronic  purulent  process,  inflammation  of  this  cavity  may  become  a 


Fig.  44.— Sinuses  leading  through  Mastoid  Coktex   from  Antrum  and  Ttkpanuv,  in  a 
Child.    From  a  Photograph. 

very  serious  affair.  Thus  with  an  acute  exacerbation  of  the  disease, 
the  escape  of  purulent  matter  into  the  atrium,  auditory  canal,  or 
Eustachian  tube  may  be  effectually  prevented,  just  as  we  find  in  acute 
processes,  and  extension  of  the  inflammation  to  the  cranial  cavity  ia 
likely  to  occur. 


OTITIS   MEDIA   SUPPURATIVA   CHKONICA.  291 

When  the  proportionately  large  area  of  the  middle  ear  tract  in  chil- 
dren is  considered,  one  need  not  experience  any  surprise  at  the  fre- 
quency of  its  serious  invasion  by  disease.  The  tympanum,  antrum, 
and  Eustachian  tube  thus  comprise  a  very  much  exposed  region  occupy- 
ing a  dangerous  proximity  to  the  dura  mater,  being  separated  by  an 
extremely  thin  plate  of  bone,  often  imperfectly  closed  by  osseous 
tissue  specially  along  the  line  of  the  petro-squamosal  suture.  Free 
vascular  communication  is  afforded  through  this  thin  partition  be- 
tween the  middle  ear  and  the  dura,  and  during  any  inflammatory  prp- 
cess  in  either,  the  other  is  extremely  liable  to  be  affected. 

It  is  in  these  cases  of  obstructed  drainage,  especially  in  children, 
that  severe  symptoms  develop;  periosteal  inflammation,  both  inter- 
nal and  external,  with  tympano-mastoid  abscess  and  caries  of  the 
bone,  transforming  a  simple  case  into  a  grave  one.  As  a  result  of 
external  periosteal  inflammation,  we  shall  often  observe  denudation 
of  bone  and  caries  of  the  mastoidea,  and,  when  at  the  same  time 
internal  periosteal  inflammation  extends  deeply  into  the  mastoid  cel- 
lules, perforation  of  the  cortex  takes  place  either  through  the  pos- 
terior wall  of  the  canal  or  through  the  process  behind  the  auricle  (see 
Fig.  44).  Fungosities  at  these  outlets,  especially  at  the  former, 
springing  up  from  the  cellules,  are  usually  present  and  often  redun- 
dant. 

Exfoliation  of  Sequestra.  During  the  continuance  of  inflamma- 
tion of  the  mastoid  cellules,  the  granulation  tissue  which  fills  them 
and  any  sinuses  leading  to  the  cortex  of  the  mastoid  process,  into  the 
external  auditory  canal  or  into  the  tympanum,  envelops  and  absorbs 
minute  sequestra.  This  will  not  take  place  while  they  are  immersed 
in  pus  only.  Furthermore,  as  a  result  of  the  necrotic  process  estab- 
lished in  the  cellules,  sequestra  of  various  sizes  become  detached,  and 
may  be  detected,  by  the  probe,  in  the  diseased  cavity  of  the  mastoid. 
If  a  free  outlet  for  the  secretions  is  not  afforded  by  the  communica- 
tion with  the  tympanum  or  the  external  auditory  canal,  a  fistulous 
opening  through  the  mastoid  process  is  formed.  Sometimes  a  large 
sequestrum  presents  at  the  outlet  of  these  drainage-tracts,  much  to 
the  patient's  relief.  The  carious  cavity  often  gives  rise  to  excessive 
purulent  secretion,  when  small  fragments  of  bone  are  carried  out  of 
the  ear  without  being  observed.  Small  sequestra  carried  out  along 
with  secretions  are  doubtlessly  sometimes  reported  as  being  the 
ossicles. 

Minute  sequestra,  embedded  in  granulation  tissue,  disappear,  as 
just  stated,  by  absorption,  a  process  similar  to  the  physiological  ab- 
sorption of  the  roots  of  deciduous  teeth  through  vascular  papillae. 


292  OTITIS   MEDIA    SUPPURATIVA   CHKONIOA. 

Injury  of  the  facial  nerve,  where  it  passes  through  the  aquaeductus 
Fallopii,  may  be  caused  by  necrosis  or  by  the  pressure  of  a  seques- 
trum in  transit,  in  which  event  a  facial  paralysis  would  occur. 
Slight  paresis  only,  however,  may  result  from  such  an  injury  to  the 
nerve,  the  palsy,  when  not  great,  being  liable  to  escape  notice. 

Sometimes  large  sequestra,  consisting  of  portions  of  the  auditory 
or  tympanic  plate  or  of  portions  of  bone  containing  the  cochlea  or 
semi-circular  canals,  are  removed  in  these  cases,  especially  in  broken- 
down  or  scrofulous  subjects  (see  Chap.  XV.).  It  is  surprising  to 
witness  the  rapidity  with  which  recovery  often  takes  place  after  the 
detachment  of  very  large  pieces  of  temporal  bone. 

Among  131  more  grave  cases  of  the  author's'  (65  acute  and  66 
chronic),  exfoliation  occurred  with  about  equal  frequency  through 
the  mastoid  process  and  external  auditory  canal.  Of  these  131  cases 
25  per  cent  had  periostitis  externa  with  abscess  over  the  mastoid  pro- 
cess; 23  per  cent  had  tympano-mastoid  abscess;  16  per  cent  had  per- 
forative necrosis  of  the  cortex;  x!l  per  cent  had  caries  of  the  tympanic 
walls;  14  per  cent  had  facial  paralysis;  24  per  cent  had  polypoid 
tumors.  ' 

The  results  of  inflammation  of  the  mastoid  cellules  are  usually 
either  induration  or  atrophy  of  the  osseous  structure.  Since  the 
rudimentary  cellules  of  the  mastoid  in  children  are,  when  inflamed, 
liable  to  become  obliterated,  the  parts  in  later  years  may  present 
dense  bony  structure  instead  of  cellules. 

The  temporal  bone,  like  other  bones  of  the  skull,  is  supplied  with 
nutrient  vessels  both  from  its  outer  and  its  inner  surfaces  (the  dura 
mater  and  periosteum).  The  middle-ear  tract  is  inserted  between 
these  surfaces,  and  has  a  mucous-periosteal  lining  of  its  own.  This 
large  space  within  the  bone,  divided  into  larger  and  smaller  cellules, 
is  surrounded  for  the  most  part  by  a  very  thin  shell  of  bone.  There 
are  thus  four  surfaces,  each  with  its  own  arterial  supply;  and  this 
supply  is  sufficient  so  that  when  the  periosteum  (or  corresponding 
endosteum)  is  destroyed  on  one  side  no  necrosis  or  caries  usually 
results  therefrom.  Thus  either  the  external  periosteum,  and  the 
outer  layer  of  the  dura  mater  (which  is  the  internal  periosteum),  or 
the  mucous-periosteal  membrane,  or  exosteum,  lining  the  entire 
middle-ear  tract,  may  be  destroyed  without  materially  affecting  the 
nutrition  of  the  bone.  Inflammation  of  both  internal  and  external 
mastoid  surface  is,  probably,  usually  necessary  for  the  complete  de- 
struction of  the  cortical  layer. 

'  Transactions  of  the  American  Otological  Society,  1886. 


OTITIS   MEDIA    SUPPURATIVA   CHKOJSnCA.  293 

Of  course,  it  must  be  remembered,  that  all  the  subjective  phe- 
nomena, such  as  vertigo,  pain,  and  so-called  brain  symptoms,  brought 
about  by  these  pathological  conditions  occurring  in  the  course  of 
chronic  purulent  processes  of  the  middle  ear,  or  acute  exacerbations 
of  such,  are  similar  in  every  way  to  those  described  with  acute  puru- 
lent otitis  media;  it  is,  therefore,  unnecessary  to  repeat  them  here. 

The  gravity  of  these  cases  does  not  depend  so  much  on  the  lia- 
bility to  transmissions  of  the  purulent  process  to  the  brain  as  on  the 
local  and  constitutional  symptoms  arising  in  neuropathic  or  cachectic 
persons,  especially  when  subjected  to  meddlesome  treatment.  The 
pernicious  effects  of  over-treatment  are  seen  in  a  large  number  of 
difficult  cases,  of  which  the  following  is  an  example:  A  male,  45 
years  of  age,  was  suffering  from  an  acute  purulent  inflammation  of 
the  middle-ear  tract.  Severe  neuralgic  pains  were  experienced,  but 
there  was  free  drainage.  In  consequence  of  the  copious  syringing 
and  instillation  of  antiseptic  and  astringent  solutions  for  the  relief  (?) 
of  symptoms  the  discharge  was  promptly  suppressed,  and  the  aggra- 
vation was  so  great  that  periostitis  of  the  external  auditory  canal  and 
mastoid  process  developed.  Fluctuation  over  the  mastoid  was  de- 
tected before  the  drainage  was  again  fully  reestablished  from  the 
tympanum.  When  first  seen  by  the  writer,  there  was  intermittent 
fluctuation;  the  opening  in  the  drum-head  afforded  escape  for  the  puru- 
lent matter  for  a  day  or  two,  when,  on  closing,  fluctuation  would  again 
appear  over  the  mastoid.  This  alternate  collection  and  escape  of 
matter  from  the  drum  was  relieved  by  free  incision  through  the  drum- 
head and  over  the  mastoid,  but  in  the  mean  time  perforation  of  the 
cortex  of  the  mastoid  process  had  taken  place. 

Whether  occurring  in  otherwise  healthy  or  in  unfavorable  sub- 
jects, there  is  usually  a  history  of  this  kind  or  of  exacerbation  from 
exposure. 

In  children  the  course  of  purulent  inflammation  is  somewhat  dif- 
ferent, since  the  mastoid  cellules  are  wanting,  though  the  antrum 
is  fully  developed.  Defects  in  the  tegmen  are  not  uncommon,  and 
meningitis  and  cerebral  abscess  probably  occur  more  frequently  than 
later  in  life. 

In  severe  cases  (whether  so  at  the  beginning  or  by  subsequent  ag- 
gravation) inflammation  of  the  periosteal  lining  of  the  tympanum 
often  extends  by  continuity  of  tissue  very  rapidly,  both  internally 
and  externally.  The  exacerbation  may  or  may  not  be  ushered  in  with 
a  chill,  but  there  is  usually  elevation  of  temperature  and  frequency  of 
pulse. 

It  often  happens,  especially  in  run-down  subjects,  that  all  of  the 


294  OTITIS   MEDIA    STJPPUR A.TIVA   CHRONICA. 

outlets  become  prematurely  closed,  or  blocked  up  by  exuberant  gran- 
ulation tissue,  polypi,  or  escaping  sequestra,  so  as  to  confine  the  pro- 
ducts of  inflammation,  thus  causing  an  exacerbation  of  the  symptoms. 
Under  these  conditions  an  intermittent  discharge  is  established,  an 
outlet  breaking  open  so  soon  as  the  pressure  of  secretions  reaches 
a  certain  point.  When  the  retained  secretions  are  increased  by  the 
appearance  of  a  head  catarrh,  these  exacerbations  are  much  more 
severe.  If  no  operative  procedures  are  undertaken  for  the  relief  of 
symptoms  due  to  pent-up  secretions,  and  thus  giving  free  vent  to  them 
through  the  tympanum,  or  at  the  site  of  a  closed  sinus,  of  course 
sooner  or  later  spontaneous  rupture  of  one  of  the  obstructed  outlets 
affords  relief.  But,  when  thus  neglected,  they  may  be  protracted 
for  weeks  or  months,  their  course  being  characterized  by  alternate 
*' gathering  and  breaking." 

The  following  cases  where  grave  symptoms  occurred  are  instructive 
and  illustrate  certain  phenomena  better  than  a  general  description: 

Case  1. — W.  T,,  aged  18  years,  came  on  account  of  an  exacerba- 
tion of  a  chronic  purulent  inflammation  of  the  right  ear  which  had 
existed  since  an  attack  of  measles  six  years  previously.  He  was 
examined,  and  treated  for  the  severe  pain  in  the  ear,  but  did  not 
return.  His  mother,  however,  came  a  few  days  later  stating  that 
he  had  died  on  the  second  day  after  his  visit  of  "acute  cerebral 
meningitis."  The  physicians  in  attendance  were  unaware  of  the 
existence  of  any  aural  complication. 

Case  2. — Periostitis  externa  and  interna,  the  result  of  an  acute 
exacerbation  of  a  chronic  purulent  process,  resulted  quickly  in  a  per- 
foration of  the  cortex  of  the  mastoid  and  relief  of  the  symptoms — ■" 
sequestration  having  occurred  through  the  sinus  outwardly.  Dermic 
transformation  took  place  throughout  the  pathological  tract  of  the 
middle  ear. 

Case  3. — Resembled  the  foregoing,  but  drainage  was  established 
through  the  sac  of  a  temporo-mastoid  abscess  opening  into  the  pos- 
terior wall  of  the  external  auditory  canal,  giving  exit  also  to  an 
osseous  exfoliation.  [In  this  case  denudation  of  the  periosteum  was 
detected  by  the  probe,  which  could  be  passed  backward  and  down- 
ward along  the  course  of  purulent  tract  from  the  opening  in  the 
canal  to  the  apex  of  the  mastoid  process.  The  burrowing  of  the 
purulent  accumulation  coming  from  the  tympanum  and  extending 
outwardly  beneath  the  integument  of  the  canal  was  not  arrested  in 
its  progress  until  a  point  below  this  on  the  neck  was  reached.  The 
accumulation  present  in  this  case  might  have  been  attributed  to  a 
discharge  through  a  perforation  in  the  apex  of  the  mastoid  process, 
had  not  the  examination  determined  its  source  in  the  tympanum.] 

In  another  instance  the  unfavorable  symptoms  were  still  more 
marked : 


OTITIS   MEDIA    SUPPURATIVA   CHKONICA.  295 

Case  4. — Male,  aged  24  years,  with  chronic  purulent  inflamma- 
tion of  the  middle  ear.  Patient  was  a  drunkard,  and  suffered  from 
tubercular  deposits  in  the  lungs.  He  had  been  using  a  nasal  douche 
for  the  relief  of  ozena,  and  this  was  believed  to  have  caused  the 
acute  exacerbation  of  the  purulent  process  in  the  ear  for  which  he 
came  for  treatment.  On  examination,  it  was  found  that  the  mem- 
brana  flaccida  was  detached  and  that  a  dissecting  abscess  extended 
from  the  attic  of  the  tympanum  to  the  mastoid  process,  which  was 
swollen.  Discharge  from  the  canal  had  ceased.  There  was  pyrexia, 
and  accelerated  pulse — 124  beats  per  minute.  The  patient  refused 
to  have  the  attic  opened  by  an  operation,  but  relief  occurred  shortly 
afterwards  by  a  spontaneous  rupture  of  the  membrana  flaccida.  The 
patient  continuing  his  dissipated  habits,  disappeared  when  thus  tem- 
porarily relieved.  It  was  afterwards  learned  from  the  family  physi- 
cian, that  he  died  nine  months  after  this  with  symptoms  of  pneu- 
monia. 

Facial  palsy  sometimes  occurs  during  the  progress  of  chronic 
purulent  inflammation  of  the  middle  ear,  since  the  inner  wall  of  the 
tympanum  through  which  the  facial  canal  passes  often  becomes 
carious  and  necrotic,  with  consequent  injury  of  the  nerve.  The 
resulting  neuritis  may  be  either  an  ascending  or  descending  one, 
the  latter  often  being  accompanied  by  intense  pains  in  the  mastoidea 
and  parts  contiguous  to  the  course  of  the  nerve.  The  reader  should 
consult  Chapter  XV.,  where  facial  palsy  is  treated  of  more  at  length. 
In  early  life  grave,  and  even  fatal,  ear  disease  is  of  much  more 
frequent  occurrence,  probably,  than  is  generally  suspected.  In  the 
two  following  cases,'  however,  occurring  in  very  young  infants,  early 
evidence  was  not  wanting,  even  to  the  inexperienced,  of  serious 
aural  trouble,  and  death  was  due  to  neglect  and  ill-directed  treat- 
ment. 

Case  5. — Otitis  media  purulenta  chronica.  Polypus.  Facial 
paralysis.     Pachymeningitis.     Death. 

Male  infant,  6  months  of  age,  was  brought  to  the  author's  clinic, 
at  the  New  York  Eye  and  Ear  Infirmary,  in  March,  1884,  with  the 
following  history: 

When  3  months  old,  he  had  been  exposed  to  a  draught  coming 
through  an  open  window  of  a  railway  carriage.  A  few  days  after- 
wards, a  circumauricular  swelling  was  observed  to  take  place,  which 
was,  by  order  of  the  attending  physician,  poulticed  for  three  weeks 
continuously.  The  purulent  matter  which  had  been  collecting  was 
then  liberated  by  a  lancet.  After  discharging  a  week,  the  opening 
was  allowed  to  close,  but  subsequently  it  was  again  opened  and 
dressed  with  a  tent  and  some  antiseptic  ointment.  The  ear  and 
wound  were  syringed  three  times  a  day  with  an  aqueous  solution  of 

'  Transactions  of  the  American  Otological  Society,  1885. 


296  OTITIS   MEDIA   SUPPURATIVA   CHRONICA. 

one  drachm  of  carbolic  acid  to  the  pint,  the  solution  passing  freely 
through  from  the  wound  into  the  canal.  This  treatment  had  been 
persisted  in  until  the  date  of  coming  to  the  Infirmary.  The  child's 
mother  thinks  two  sequestra  of  considerable  size  were  removed  by 
the  syringing  about  four  weeks  ago.  The  discharge,  it  was  alleged, 
varies  from  time  to  time,  and  is  now  absent.  The  child  nurses  well 
and  sleeps  fairly  well. 

Examination.  The  lumen  of  the  external  auditory  canal  is  ob- 
structed with  pus,  the  removal  of  which  brings  to  view  a  large  poly- 
poid growth  filling  the  canal.     There  is  partial  right  facial  paralysis. 

March  13th.  Discharge  from  the  ear  and  sinus  more  free  to-day, 
but  the  child  is  restless.  The  polypus  was  removed  with  the 
snare  It  was  found  to  be  of  much  greater  size  than  had  been  ex- 
pected, filling  the  tympanum  and  canal  almost  to  the  meatus  ex- 
ternus.  It  was  about  one-half  inch  in  length,  and  somewhat 
nodulated.  There  was  free  hemorrhage  after  avulsion,  which  was, 
however,  soon  arrested  by  instillations  of  hot  water. 

The  treatment  consisted  in  gentle  cleansing  with  warm  water,  as 
required,  afterwards  dressing  the  parts  with  calendula  and  boracic 
acid.  Internally,  the  calcium  sulphide,  in  small  doses,  was  given 
several  times  daily. 

March  15th.  There  is  diminution  in  the  quantity  of  the  discharge, 
which  is  less  purulent.  General  appearance  is  better,  and  the  rest- 
lessness which  existed  before  the  operation  is  less. 

The  writer  did  not  again  see  the  patient;  his  mother,  however,  came 
several  months  after  to  the  Infirmary  to  report  his  death.  She  said 
that  the  next  day  after  his  last  visit  he  became  more  restless,  had  a 
cough,  and  raised  mucus.  Vomiting  occurred  after  nursing  or  tak- 
ing food  or  medicine,  and  continued  until  death,  which  took  place 
on  April  5th.  The  child  ceased  to  nurse  three  days  before  death,  and 
for  two  days  no  discharge  from  either  the  meatus  or  sinus  was  ob- 
served. He  had  convulsions  for  two  weeks,  at  the  beginning  of  which 
"his  face  became  straight  again  "  (double facial  paralysis),  and  at  the 
end  there  was  strabismus.  These  symptoms,  taken  together  with  the 
previous  history,  point  to  pachymeningitis.  It  seems  probable  that 
the  rapid  recurrence  of  the  polypoid  growth,  blocking  up  the  outlets, 
and  preventing  drainage,  may  have  hastened  the  result.  The  physi- 
cian who  attended  the  patient  at  home  certified  that  he  died  of 
''pneumonia,  convulsions,  and  dentition." 

Case  6. —  Otitis  media  purulenta  chronica  complicated  with  lymph- 
adenoma  of  the  neck,  resulting  in  caries  of  the  temporal  hone.  Facial 
paralysis.     Meningitis  purulenta.     Death.     Autopsy. 

Albert  S.,  a  Mulatto,  aged  7  months.  The  patient  was  brought  to 
the  New  York  Eye  and  Ear  Infirmary  in  June,  1885,  with  the  follow- 
ing history: 

Three  months  previous  to  this  date,  a  small  swelling  appeared  in 
front  of  the  left  tragus,  coincident  with  a  purulent  discharge  from 
the  left  ear.  The  swelling  extended  downward,  rapidly  enlarging, 
forming  a  large,  irregular  mass,  occupying  the  whole  of  the  left  side 
of  the  neck.  One  month  ago,  the  otorrhcea  ceased  almost  entirely, 
and  at  the  same  time  the  child  was  taken  to  a  city  dispensary,  and 


OTITIS   MEDIA    SUPPURATIVA   CHRONICA. 


297 


placed  under  local  and  general  medicinal  treatment  for  the  glandular 
tumor. 

During  this  period  of  treatment  the  tumor  fluctuated  in  size,  a 
discharge  appeared  in  the  right  ear,  and  the  child  became  very  rest- 
less and  irritable,  sleeping  poorly,  attacks  of  vomiting  alternating 
with  diarrhoea;  and  left  facial  paralysis  was  noticed  for  the  first 
time. 

Examination,  June  1st.  The  left  meatus  was  occluded  by  granu- 
lation tissue,  which  was  removed,  giving  vent  to  a  large  quantity  of 
very  offensive  purulent  matter.  The  canal  was  dilated,  the  posterior 
and  inferior  walls  showing  an  ulcerated  granular  surface,  the 
drum-head  was  entirely  destroyed,  and  the  tympanum  presented  a 


Fig.  45. 

large  cavity  caused  by  the  necrotic  destruction  of  portions  of  the 
annulus  tympanicus  and  temporal  plate,  the  inner  wall  of  the  attic 
and  atrium,  the  antrum  and  auditory  plate.  In  a  word,  the  bony 
walls  of  the  large  pathological  cavity  thus  exposed  to  view  were  de- 
nuded in  every  direction  ;  the  ossicles  were  absent  with  the  exception 
of  the  stapes,  which  could  be  seen  lying  loosely  upon  the  upper  and 
posterior  part  of  the  inner  wall.  The  right  meatus  was  filled  with 
granulation  tissue  which  sprouted  from  the  walls  of  the  canal,  the 
drum-head  was  destroyed,  and  denuded  bone  could  be  detected  with 
the  probe  in  any  portion  of  the  tympanum.  On  the  left  side  of  the 
neck,  there  were  a  number  of  lymphadenomata  forming  a  large,  ir- 
regular tumor,  limited  above  by  the  inferior  attachment  of  the  auricle. 


298  OTITIS   MEDIA    SCPPUKATIVA   CHRONICA. 

and  below  by  the  level  of  the  thyroid  gland.  No  fluctuation  could  be 
detected  in  any  portion  of  the  mass.  There  was  complete  left  facial 
paralysis. 

Treatment.  The  tincture  of  aconite,  ,and  calcium  sulphide  were 
given,  the  canals  being  cleansed  and  powdered  boracic  acid  insuf- 
flated once  daily.  During  the  next  eight  days  the  patient's  condition 
improved  somewhat. 

June  8th,  restless  and  irritable,  with  some  febrile  movement,  tem- 
perature 103°;  frequent  vomiting.     Discharge  from  ears  free. 

June  10th.  The  patient  became  drowsy  and  stupid,  had  general 
convulsions;  coma  supervened,  and  patient  died  on  June  12th. 

Autopsy.  The  dura  mater  is  healthy,  with  the  exception  of  that 
portion  covering  the  superior  surface  of  the  left  petrous  bone,  which 
is  much  thickened  from  the  deposit  of  neoplastic  tissue,  and  at  points 
presents  isolated  centres  of  ossification. 

There  is  purulent  meningitis  of  the  convexity,  the  deposit  of 
lymph  being  more  particularly  noticeable  along  the  margins  of  the 
longitudinal  fissure,  and  on  the  under  surface  of  the  anterior  and 
posterior  cerebral  lobes.  The  cortical  substance  is  quite  soft,  and 
there  is  considerable  accumulation  of  greenish,  offensive  matter  in 
the  subarachnoidean  cavity.  No  connection  could  be  traced  between 
the  ear  and  glandular  enlargement  on  the  neck. 

The  accompanying  cut,  Fig.  45,  somewhat  enlarged,  shows  the  outer 
surface  of  the  left  temporal  bone  after  the  specimen  had  been  pre- 
pared. The  absence  of  the  osseous  portion  of  the  external  auditory 
canal  at  this  age  brings  the  inner  wall  of  the  tympanum,  which  is 
very  large,  well  into  view;  1  is  the  promontory  of  the  inner  wall, 
and  just  above  it  is  the  foramen  rotundum  from  which  the  stapes 
has  escaped.  The  inner  wall  of  the  attic  was  gone,  exposing  the 
horizontal  semi-circular  canal.  The  walls  of  the  antrum  and  the 
adjacent  cellules  were  eroded  away,  and  the  entire  auditory  plate 
was  honey-combed.  The  auditory  plate,  5,  which  was  scarcely  united 
to  the  squamous  and  mastoid  portions,  was  undergoing  sequestration, 
entirely  denuded,  and  a  sinus,  6,  afforded  communication  between 
the  antrum  and  an  abscess  beneath  the  periosteum. 

The  annulus  tympanicus  composing  the  anterior  wall  of  the  ex- 
ternal auditory  canal  is  shown  at  2:  it  is  roughened  all  around,  as  is 
the  tympanic  plate  itself.  The  rudimentary  mastoid  process  is  seen 
at  3;  the  under  surface  of  the  petrous  bone  at  4.  The  squamous  por- 
tion is  shown  at  7,  7;  the  parietal  bone  at  8,  8. 

On  the  inner  surface  of  the  specimen,  not  shown  in  the  cut,  is 
seen  an  extensive  opening  along  the  line  of  the  petro-squamosal 
suture  through  which,  probably,  the  inflammatory  process  extended 
to  the  dura. 

It  is  probable  that  in  this  case  the  inflammation  extended  itself 
from  the  tympanum  along  underneath  the  auditory  plate  into  the 
antrum,  whilst  a  periostitis  externa  manifested  itself  on  the  outer 
surface. 

In  reviewing  Case  5,  it  seems  remarkable  that  so  little  nervous 
irritability  existed  during  the  progress  of  the  case,  although  the  ear 


OTITIS   MEDIA   SUPPURATIVA   CHRONICA. 

was  deeply  attacked.  With  the  exception  of  the  last  two  or  three 
weeks,  the  child  suffered  but  little,  and  so  far  as  pain  was  concerned, 
it  may  not  have  seemed  important  to  the  ordinary  observer. 

To  the  retention  of  secretions,  the  formation  of  which  was  actively 
promoted  by  the  three  weeks^  persistent  poulticing,  and  perhaps 
also  to  the  vigorous  syringing,  was  doubtless  largely  due  the  gravity 
of  this  case. 

Middle-ear  inflammation  in  children  often  gives  rise  to  symptoms 
well  calculated  to  puzzle  the  general  practioner,  and  hence  its  pres- 
ence is  liable  to  be  unsuspected;  thus  in  Case  5,  the  alleged  cause  of 
death  as  reported  to  bureau  of  vital  statistics  did  not  include  the 
aural  trouble. 

The  important  knowledge  to  be  obtained  by  observing  the  phenom- 
ena manifesting  themselves  in  the  ear  in  children  is  not  available 
always  without  an  expert  examination;  and  this  becomes  a  much 
more  difficult  matter  when  exterior  manifestations  are  wanting,  since 
deafness  and  distressing  autophonia,  etc.,  cannot  always  be  explained 
by  children,  and  never  by  very  young  infants,  and  pain  in  such 
cases  may  be  relegated  to  another  region.  Although  recovery  may 
take  place  when  the  aural  symptoms  are  not  recognized,  yet  deafness 
may  remain. 

In  these  neglected  cases  it  is  well  to  remember  that  the  danger 
does  not  lie  in  an  invasion  of  the  mastoid  cellules,  since  the  mastoid 
process  exists  in  a  rudimentary  state  only  before  the  age  of  puberty, 
but  in  an  extension  of  the  inflammatory  process  to  the  antrum,  caries 
of  the  bone  being  consecutive  thereto.  An  independent  but  coinci- 
dental attack  of  periostitis  externa  may,  indeed,  take  place.  Where 
the  latter  occurs  alone,  recovery  is  usually  much  more  rapid,  since, 
under  proper  treatment,  reabsorption  of  pus  takes  place,  or  it  is 
evacuated  by  the  knife. 

Treatment,  In  the  treatment  of  chronic  purulent  inflammation 
of  the  middle  ear,  it  will  be  well  to  consider  the  cases  under  three 
groups,  namely:  I.,  those  having  a  tendency  to  recovery  without  great 
loss  of  the  function  of  the  transmitting  apparatus;  II.,  these  cases  in 
which  irremediable  impairment  of  the  transmitting  mechanism  has 
taken  place;  and  III.,  grave  and  complicated  cases.  In  the  first- 
named  cases  our  object  should  be  to  restore  the  organ  to  as  great 
usefulness  as  possible;  in  the  second  instances,  to  remove  the  irreme- 
diable and  defective  structures  which  interfere  either  with  drainage 
or  the  entrance  of  sound  to  the  drum.  The  treatment  of  the  grave 
cases  will  be  considered  further  on.  In  accomplishing  the  above  ob- 
jects, the  surgeon  should  not  lose  sight  of  the  importance  of  aiding 


300 


OTITIS   MEDIA.    SITPPTIRATIVA   CHRONICA. 


the  ofl&ces  of  nature  in  two  essential  particulars,  namely,  the  main- 
tenance of  good  drainage  from  the  middle  ear  and  the  improvement 
of  the  general  healtli  of  the  patient. 

The  experience  afforded  by  the  sometimes  grave  complications  of 
chronic  purulency  should  admonish  the  physician  not  to  neglect  any 
of  these  cases,  even  when  mild.  A  temporizing,  meddlesome  treat- 
ment of  chronic  purulent  inflammation  of  the  middle  ear  by  local 
cauterization,  astringents,  and  the  like,  has  justly  brought  a  certain 
amount  of  odium  or  distrust  upon  this  special  branch  of  practice, 
since  it  may  be  continued  almost  indefinitely  without  beneficial  re- 
sults, and  interrupting,  in  some  instances,  the  natural  tendency  to  a 
cure.  The  surgeon  should,  therefore,  at  the  onset  adopt  a  rational 
plan  of  treatment  suited  to  each  particular  case,  avoiding  abusive 
methods.     With  the  counsel  of  the  family  physician,  when  available,. 


FiQ.  46. — The  Authoe's  Combination  Ear  Forceps,  having  four  adjustable  operating  points, 
namely  :  1.  Scissors,  for  clipping  off  redundant  tissue  from  the  walls  of  the  canal ;  2.  Serrated 
Dressing  Forceps ;  3.  Cutting  Forceps,  for  biting  off  granulatons,  etc. ;  4.  Foreign  Body 
Forceps. 


a  general  course  of  treatment,  including  especially  hygienic  measures, 
should  be  insisted  on,  all  causative  influences,  elsewhere  considered 
in  these  pages,  being,  if  possible,  removed  before  any  local  treatment 
is  commenced.  The  presence  of  severe  nasal  catarrh,  diseased  teeth, 
etc.,  if  not  attended  to  may  prevent  any  favorable  impression  from 
local  treatment  taking  place.  These  matters  having  been  provided 
for,  the  relief  of  purulency  may  then  be  attempted  by  local  measures. 
I.  Where  the  mucous  tract  of  the  middle  ear  is  the  source  of  dis- 
charge, and  there  is  no  hindrance  to  drainage,  a  cure  may  confidently 
be  expected  from  cleanliness  alone;  and  in  by  far  the  greater  num- 
ber of  cases,  healing  of  the  perforations  in  the  drum-head  will  also 
take  place.     Should  the  perforation,  however,  show  no  disposition  to 


OTITIS   MEDIA   8ITPPTJRA.TIVA   CHRONICA. 


301 


•close,  its  edges  may  be  gently  stimulated  by  some  irritant.  The  in- 
sertion of  an  eyelet,  such  as  has  been  recommended  for  keeping  per- 
forations open,  would  afford  the  necessary  stimulation  to  bring  this 
about.  It  must  be  borne  in  mind,  however,  that  very  often  the 
closure  of  a  perforation  is  followed  by  a  decrease  of  the  hearing 
power. 

Where  granulation  tissue  or  polypi  have  developed  in  the  drum  or 
antrum,  they  must  first  be  removed  before  other  treatment  is  at- 
tempted. The  management  of  aural  polypi  will  be  considered  in  a 
separate  chapter  (XIV.).  Granulation  tissue  is  best  removed  with  in- 
struments; cutting  forceps  and  cutting  curette  may  be  employed  for 
this  purpose.     Granulation  tissue  generally  shows  a  tendency  to  rapid 


Fig.  47.— The  Author's  Glass  Aural  Stbinge  (half  natural  size),  with  hard-rubber  tips  and 
mountings. 


reproduction,  and  so  long  as  the  general  condition  of  the  patient  is 
unfavorable,  local  treatment  is  well-nigh  useless,  reproduction  often 
taking  place  in  a  day  or  two.  Where  granulation  tissue  occupies  the 
attic  or  antrum  and  cannot  be  reached  with  instruments,  the  insuffla- 
tion of  salicylic  acid  or  the  introduction  of  an  ethereal  solution  of  this 
drug,  answers  well.  The  writer,  in  some  cases,  employs  this  remedy 
in  the  atrium,  especially  to  the  base  of  masses  that  have  been  removed 
with  instruments.  The  applications  should  be  made  daily,  or  at 
longer  intervals  as  required.  Since  humidity  is  known  to  favor  the 
growth  of  granulation  tissue,  the  parts  should  be  kept  dry,  the  ear 
syringed  as  seldom  as  possible,  all  moisture  being  gently  removed  by 
means  of  absorbent  cotton  wound  on  the  end  of  a  carrier.  In  most 
cases,  the  introduction  of  solutions  or  powders  is  harmful,  irritating 


302  OTITIS   MEDIA    SUPPURATIVA   CHRONICA. 

the  mucous  membrane  only  further.  They  should  not  be  employed 
unless  with  the  object  of  transforming  the  mucous  membrane  of  the 
tympanum  into  a  dermoid  state. 

When  the  general  system  of  the  patient  is  in  an  unfavorable  state 
scarcely  any  change  may  ^es^^lt  from  treatment  for  months  or  years, 
no  matter  what  methods  have  been  employed. 

II.  Where  a  large  portion  of  the  membrana  vibrans  has  been  lost, 
with  or  without  ankylosis  of  some  or  all  of  the  ossicular  articulations,, 
the  treatment  will  consist  of  measures  for  the  repression  of  otorrhoea. 
and  the  removal  of  polypi  and  granulation  tissue  as  before  alluded 
to.  Our  object,  however,  in  these  cases  will  be  to  convert  the  mucous 
lining  of  the  middle-ear  tract  into  a  non-secreting  or  cicatricial  surface, 
for  it  will  be  no  longer  possible  to  restore  the  formal  functions  of  the 
transmitting  mechanism.  We  must  now  endeavor  to  improve  the 
condition  of  the  parts  so  as  to  secure  the  admission  of  sound  in  order 
that  impact  may  take  place  directly  upon  the  base  of  the  stapes  and 
the  membrana  tympaui  secundaria.  After  removing  any  polypi  or 
granulation  tissue  present,  the  drum  may  be  packed  with  drying 
powders  or  salicylic  acid;  the  instillation  of  absolute  alcohol  in  some 
cases  answers  better.  Granulation  tissue  may  be  treated  by  compres- 
sion with  powdered  boracic  acid  well  packed  into  the  atrium,  if  the 
membrana  vibrans  is  absent,  or  nearly  so,  and  the  presence  of  the 
powder  does  not  interfere  with  drainage.  Where  the  secretions  are 
putrid,  an  occasional  application  of  a  45^  solution  of  the  peroxide 
of  hydrogen  is  often  beneficial.  This  treatment,  persisted  in  for  a 
longer  or  shorter  time,  may  be  followed  by  a  cure  with  fairly  good 
hearing.  But  often,  owing  to  the  persistency  of  the  inflammatory 
process  in  regions  beyond  the  atrium,  namely,  in  the  attic  and  antrum,, 
or  mastoid  cellules,  secretions  form  and  are  retained,  and  remedies 
cannot  be  applied  to  the  diseased  parts;  or  the  presence  of  the  de- 
fective mechanism  and  results  of  the  inflammatory  process,  such  as 
newly-formed  bands,  ankylosis  of  the  ossicles,  and  retained  secre- 
tions which  have  undergone  inspissation,  interfere  with  the  entrance. 
of  sound.  Under  such  circumstances  the  operation  of  excision  of 
the  drum-head  and  ossicles  is  to  be  considered,  and  will  be  discussed 
in  detail  further  on  (Chapter  XVII.). 

Where  a  sinus  exists  leading  up  into  the  attic,  either  in  front  of 
or  behind  the  short  process  through  the  membrana  flaccid  a,  the 
membrana  vibrans  remaining  intact,  we  may  often  bring  about  a 
cure  by  thoroughly  clearing  out  the  tract,  usually  filled  with  thick, 
inspissated  pus,  granular  tissue,  etc.  The  cutting  forceps  or  cut- 
ting curette  can  sometimes  be  used  to  advantage  in  these  cases,. 


OTITIS    MEDIA    8UPPUEATIVA   CHRONICA.  303 

being  passed  up  along  the  sinus  far  enough  to  detach  any  growths; 
Sometimes  a  large  pathological  cavity  is  thus  opened  up  into  the 
attic,  extending  even  beyond  into  some  of  the  neighboring  cellules. 
When  such  a  passage  has  been  thoroughly  cleared  out,  the  ethereal 
solution  of  salicylic  acid  may  be  introduced  on  a  small  pledget  of 
cotton-wool  attached  to  the  end  of  a  silver  probe,  the  parts  being 
afterwards  packed  with  dry  salicylic  acid.  Where  a  large  area,  how- 
ever, consisting  of  attic  and  antrum,  is  secreting  purulent  matter,  such 
measures  are  generally  ineffectual,  and  excision  is  to  be  considered. 

III.  Where  the  mucous  membrane  of  the  antrum  and  mastoid  cel- 
lules, left  in  a  state  of  hyperemia  as  a  sequence  of  acute  purulent 
inflammation,  becomes  infiltrated  as  the  case  assumes  chronicity, 
these  cavities  have  the  appearance  of  being  filled  with  gelatinous 
matter,  as  before  alluded  to.  If  the  mastoid  cells  now  become  the 
seat  of  caries,  with  denudation,  and  the  products  of  the  process  find 
no  outlet  through  the  tympanum,  burrowing  through  the  posterior 
wall  of  the  external  auditory  canal  or  the  cortex  of  the  mastoid  pro- 
cess will  take  place,  giving  rise  to  urgent  symptoms,  owing  to  impeded 
drainage.  In  these  cases,  especially  where  pointing  indicates  the 
course  taken  by  the  pent-up  secretions,  we  should  liberate  them  by  a 
free  opening  with  the  knife. 

It  is  a  very  difficult  matter  to  decide  what  course  of  treatment 
should  be  pursued  in  the  early  stages  of  such  cases,  since  a  diagnosis 
is  by  no  means  easy.  Leaving  the  discussion  of  operative  procedures 
on  the  mastoid  with  the  drill  or  trephine  for  the  present,  the  writer 
will  proceed  to  state  what  course  seems  to  him  best  in  the  cases  under 
discussion. 

The  following  case  presents  some  of  the  conditions  which  had  best 
be  left  to  nature,  unless  the  patient  comes  under  observation  at  an 
earlier  stage  of  the  disease.  The  patient  was  a  woman,  19  years  of 
age,  who  had  been,  probably,  the  subject  of  chronic  purulent  inflam- 
mation since  childhood,  although  she  had  no  recollection  of  ever  hav- 
ing had  any  pains  in  the  ear,  or  any  discharge  therefrom,  until  a  short 
time  before  she  first  came;  she  stated,  however,  that  the  ear  had  had 
a  bad  odor  at  times  ever  since  she  was  a  child.  After  the  removal  of 
a  mass  of  polypi,  a  large  sequestrum  was  found  at  the  bottom  of  the 
external  auditory  canal,  and  which,  on  examination,  proved  to  consist 
of  a  large  fragment  of  bone  involving  the  mastoid  antrum,  some  of 
the  pneumatic  cells,  and  a  portion  of  the  roof  of  the  tympanum. 
After  these  morbid  products  were  taken  from  the  ear,  the  patient 
made  a  rapid  recovery.  Facial  paralysis,  however,  remained,  owing 
to  irreparable  injury  to  the  facial  nerve. 


304  OTITIS   MEDIA    SUPPURATIVA   CHRONICA. 

'  When,  in  caries  of  the  mastoid,  there  is  bulging  of  the  integument 
of  the  posterior  wall  of  the  canal,  decreasing  the  calibre  of  the 
latter,  the  tumefaction  having  a  purplish  appearance,  and  sometimes 
a  minute  opening,  the  parts  should  be  freely  laid  open.  This  tume- 
faction has  often  been  mistaken  for  a  polypus,  and  futile  attempts 
made  to  remove  it  with  the  snare.  It  is  difficult  to  keep  up  drainage, 
and  relief  is  often  temporary  only.  Grave  symptoms,  however,  gen- 
erally disappear  at  this  stage,  and,  indeed,  discharge  may  now  occur 
through  the  tympanum. 

Officious  surgical  meddling  in  these  cases  can  but  be  most  injurious, 
since  it  is  not  wise  to  attempt  to  separate  sequestrating  from  healthy 
bone  until  nature  has  completed  her  share  of  the  process. 

When  the  posterior  bony  wall,  periosteum,  and  integument  of  the 
external  auditory  canal  have  been  perforated  in  caries,  sequestra  pre- 
senting in  this  locality  can  very  readily  be  removed  by  gentle  manip- 
ulation; sometimes,  however,  the  canal  requires  dilatation.  It  is 
usually  necessary  to  first  bring  away  the  abundant  granular  tissue 
which  nearly  always  obstructs  the  canal,  and  fills  any  cavities  in  the 
mastoid.  The  point  of  perforation  in  young  patients  is  often  very 
near  the  outlet,  where  the  surgeon  can  easily  see  what  he  is  doing. 
Where  no  loose  sequestra  are  found,  the  case  had  best  be  left  to  the 
efforts  of  nature  so  far  as  its  surgical  aspect  is  concerned,  as  minute 
portions  of  necrotic  tissue  rapidly  pass  out  when  the  channel  is  clear, 
while  a  certain  quantity  is  absorbed.  In  some  instances  there  is 
reason  to  believe  that  sequestra  become  encysted;  of  this,  however, 
the  writer  can  offer  no  absolute  proof. 

Disease  of  the  pneumatic  cells  of  the  mastoid  may  exist  when  the 
appearance  of  the  drum-head  gives  but  little  evidence  of  any  middle- 
ear  disease;  several  instances  of  this  kind  have  been  observed.  In 
one  of  them  an  acute  and  painful  attack  came  on,  accompanied  by 
BelFs  palsy.  The  mastoid  inflammation  did  not  abate  for  several 
weeks,  and  the  palsy  lasted  much  longer.  There  were  no  marked 
acoustic  phenomena  to  indicate  disturbance  of  the  conductive  mech- 
anism in  this  case,  nor  was  the  drum-head  more  than  slightly  hyper- 
aemic  for  a  few  days.  In  another  case,  where  the  mastoid  disease 
had  existed  for  years,  the  perforation  in  the  drum-head  closed  up,  and 
good  hearing  returned;  the  purulent  secretions  from  the  mastoid,  in 
the  mean  time,  finding  an  outlet  through  the  outer  table. 

Sometimes  it  is  good  surgery,  when  clearing  the  drainage  tract  of 
granulation  tissue,  etc.,  to  cautiously  scoop  out  the  pathological 
cavern  of  the  mastoid,  using  care  to  avoid  wounding  of  the  facial 
nerve.  The  irritation  arising  from  this  procedure  is  apt  to  cause  a 
more  healthful  inflammatory  action  in  the  parts. 


CHAPTER  XIY. 

AUEAL  POLYPI. 

According  to  Schwartze,'  aural  polypi  are  found  in  4^  to  5^  of  all 
patients  with  aural  diseases,  among  males  twice  as  frequently  as 
among  females.  Below  is  appended  a  tabulated  list,  showing  the 
ages  and  sex  in  192  cases  of  the  author's  of  which  records  were 
made: 


AGE. 

KALES. 

FEMALES. 

TOTAL. 

6  weeks 

*i 

1 

3 

14 
22 

42 

15 

9 

1 
'2 

8 

6 

15 

15 

28 

10 

6 

1 

6  months 

1 

Between  1  and  3  years 

1 

Between  2  and  3      '*     

2 

Between  3  and  4      "     

3 

Between  4  and  5      "       

8 

Between  5  and  12    "     

29 

Between  12  and  18  "     

37 

Between  18  and  30  "     

70 

Between  30  and  40  "     

25 

Over  40  years 

15 

Total 

106 

86 

192 

To  the  tyro  the  precise  point  of  origin  of  polypi  is  puzzling,  and 
even  the  expert  cannot  always  determine  this  at  the  first  examina- 
tion made.  Sometimes  they  can  be  seen  with  the  unaided  eye 
presenting  at  the  meatus  externus,  or,  if  the  canal  be  large,  lying 
further  in.  Viewed  through  the  aural  speculum  they  can  often  be 
plainly  seen  to  present  on  the  surface  of  the  inner  end  of  the  canal 
or  drum-head;  but  they  never  take  their  origin  from  the  skin.  When 
observed  coming  through  the  walls  of  the  canal,  it  will  invariably  be 
found  that  they  develop  from  the  mucous  membrane  lining  the  cel- 
lules which  lie  adjacent  in  the  mastoid  or  above  the  superior  wall  of 
the  canal,  but  communicating  with  the  middle  ear.  Polypi  also 
spring  from  the  openings  of  sinuses  on  the  canal  walls,  and  which 


'  Chirurgische  Krankheiten  des  Ohres. 
20 


Stuttgart,  1885,  page  211. 


306  AURAL   POLYPI. 

afford  an  outlet  to  secretions  in  the  attic.  When  the  products  of  in- 
flammation of  the  mastoid  cellules  find  an  outlet  into  the  posterior 
wall  of  the  external  auditory  canal,  or  through  its  cortex  behind  the 
auricle,  the  sinus  at  either  of  these  vents,  as  a  rule,  becomes  filled 
with  granulation  tissue;  the  former  soon  sends  forth  fungosities 
which  may  take  on  polypoid  action,  since  the  humidity  and  warmth 
of  the  canal  are  favorable  to  such  growth;  the  latter  from  exposure 
does  not  take  on  such  action,  though,  when  freely  poulticed,  redun- 
dant masses  of  granulation  tissue  form  there. 

Polypi  do  not  grow  from  the  dermic  layer  of  the  drum-head,  but 
perforations  either  of  the  membrana  flaccida  or  membrana  vibrans 
are,  towards  the  decline  of  acute  purulent  inflammation,  often  more 
or  less  occluded  by  the  swollen  mucous  membrane  which  may  sooner 
or  later  become  the  seat  of  polypoid  growth.  In  such  cases  the 
polypi  developing  exteriorly  to  the  drum-head  may  become  large 
enough  to  occlude  the  canal,  though  attached  to  the  mucous  mem- 
brane by  a  small  pedicle  whose  size  is  limited  by  that  of  the  perfora- 
tion through  which  it  passes. 

In  the  greater  number  of  instances  where  polypi  develop  from  the 
mucous  tract  of  the  middle  ear,  considerable  loss  of  substance  in  the 
drum-head  will  be  found.  The  growth  may  arise  from  the  atrium, 
attic,  antrum,  mastoidea,  or  from  the  cellules  which  surround  the 
superior  and  posterior  walls  of  the  tympanum  and  inner  end  of  the 
external  auditory  canal;  but  in  nearly  all  instances  it  eventually  pre- 
sents itself  to  view  in  the  tympanic  cavity  or  in  the  external  auditory 
canal. 

In  rare  instances  polypi  are  observed  to  spring  from  the  handle  of 
the  malleus,  and  Burnett  reported  a  case  of  an  organized  vesicular 
polypus  which  contained  the  necrosed  long  process  of  the  incus.' 
Their  attachment  is  as  a  rule  very  slight.  In  one  of  the  author's 
cases  slight  traction  with  the  wire  snare  brought  away,  however,  not 
only  the  growth,  but  also  the  malleus  to  which  it  was  attached;  it 
is  needless  to  add,  perhaps,  that  the  drum-head  was  absent  in  this 
case.  Among  47  cases  occurring  in  the  writer's  practice,  where  the 
point  of  origin  of  the  polypi  was  ascertained,  it  was  found  that  the 
growth  started  in  the  atrium  in  26  cases,  in  the  attic  in  14  cases,  in 
the  antrum  in  2  cases,  in  the  mastoid  cells  in  1  case;  was  attached 
furthermore  to  the  handle  of  the  malleus  in  3  cases,  and  to  the 
meatus  wall  in  1  case. 
,    Polypi  are  divided  according  to  their  structure  and  nature  into 

>  Treatise  on  the  Ear.    Phila.,  1884,  page  501. 


ATJRAL   POLYPI.  307 

mucous,  fihromatous,  and  myxomatous  varieties.  The  latter  are 
rarely  met  with,  whilst  the  mucous  variety  are  the  most  common  of 
all.  The  fungosities  which  spring  up  from  the  carious  walls  of  the 
canal,  consequent  to  perforative  inflammation  of  the  mastoid,  are  fre- 
quently very  redundant  and  exceedingly  liable  to  recurrence.  They 
often  completely  occlude  the  canal  outwardly  as  far  as  the  meatus. 

The  size  to  which  polypi  may  attain  is  very  variable,  being  from 
minute  and  scarcely  recognizable  growths  to  tumors  the  size  of  a  pecan 
nut,  completely  filling  the  canal,  and  even  projecting  out  into  the 
concha.  Where  they  have  long  remained,  the  canal  sometimes  becomes 
greatly  increased  in  size  by  absorption  of  the  osseous  substance,  and 
where  polypi  keep  on  growing  during  youth,  the  canal,  in  adapting 
itself  to  the  tumor,  is  frequently  found  to  be  of  enormous  dimensions. 

In  some  cases  the  growth  is  confined  to  the  tympanum  by  a  rem- 
nant of  the  membrana  tympani;  the  middle  ear  may  thus  become 
wholly  filled  up,  or,  whore  only  a  small  perforation  exists  in  the  mem- 
brane, the  growth  may  make  its  way  through  and  develop  itself  in 
the  canal,  the  pedicle  only  remaining  inside,  as  in  the  instance  be- 
fore mentioned.  The  fibromatous  polypi  are  said  to  arise  from  the 
periosteal  layer  of  the  mucous  membrane  of  the  tympanum.  When 
they  are  found  attached  to  the  wall  of  the  external  auditory  canal, 
they  take  their  origin  from  some  sinus  leading  into  the  canal  from 
the  pneumatic  cells  which  abound  in  this  vicinity,  as  above  stated. 
These  polypi  are  very  much  tougher  than  the  mucous  variety,  and 
are  much  more  rarely  met  with.  The  clinical  history  of  some  cases 
shows  that,  on  attaining  a  certain  size,  polypi  detach  themselves 
spontaneously  and  come  away,  their  place  being  often  speedily  occu- 
pied by  a  new  polypoid  growth . 

The  symptoms  produced  by  the  presence  of  polypi  are  numerous 
and  often  severe  and  grave.  There  will  nearly  always  be  found  the 
phenomena  due  to  chronic  purulent  inflammation  of  the  middle  ear, 
such  as  otorrhoea,  etc.,  but  the  presence  of  the  growth  generally  in- 
creases such  symptoms,  and  in  addition  may  give  rise  to  otalgia  and 
other  neuralgic  symptoms,  facial  paralysis,  deafness,  autophonia,  ver- 
tigo, and  nausea,  offensive  odors  from  the  decomposition  of  pent-up 
secretions,  hemorrhage,  caries  and  necrosis  of  the  bony  structures, 
and  often  meningitis,  resulting  in  death. 

The  otalgia  and  other  neuralgic  symptoms  are,  in  great  part  at 
least,  due  to  the  pressure  of  the  tumor,  especially  when  coincident 
with  an  exacerbation  of  the  otitis  media. 

The  vertiginous  phenomena  seem  to  be  due,  in  these  cases,  either 
to  the  increase  of  labyrinthine  pressure,  the  more  direct  cerebral 


308  AUKAL    POLYPI. 

pressure  through  the  tegmen  tympani,  which  is  often  thinned  by 
previous  absorption,  or  to  the  irritation  of  the  chorda  tympani. 

Facial  paralysis  is  not  unfrequently  the  result  of  the  pressure  of 
the  neoplasm  upon  the  facial  nerve  at  some  part  of  its  course  in  the 
neighborhood  of  the  tympanum.  It  occurred  in  five  of  the  author's 
cases  given  above.  This  subject  will  receive  more  attention  in  Chap- 
ter XV. 

Deafness  will,  of  course,  be  always  more  or  less  increased  by  the 
occlusion  of  the  external  auditory  canal,  and  by  the  interference 
with  the  transmitting  mechanism,  when  an  effective  portion  of  it 
remains. 

Tinnitus  aurium  and  autophonia,  phenomena  of  frequent  occur- 
rence in  otitis  media  purulenta,  are  increased  very  often  by  the 
presence  of  polypi  in  the  tympanic  cavity.  These  acoustic  symptoms 
are  probably  much  more  pronounced  where  the  transmitting  mechan- 
ism is  not  greatly  impaired,  but  the  growth  itself  may  perform  the 
functions  of  transmission  in  the  same  manner  as  an  artificial  drum- 
head. 

The  offensive  odor,  present  in  most  cases  of  otorrhea  of  long  stand- 
ing, is  often  very  much  increased  by  the  stoppage  of  the  canal  by  the 
growth  ;  in  some  instances  the  matter  finds  an  outlet  from  the  tym- 
panum through  the  Eustachian  tube  into  the  pharynx,  when  the 
breath  of  the  patient  will  be  found  to  be  very  offensive.  It  will 
doubtless  occur  to  the  reader  that,  in  such  cases,  there  would  not  only 
be  increased  danger  from  absorption  of  the  purulent  secretions,  but 
that  the  constant  inhalation  of  depraved  air  would  likewise  be  in- 
jurious. 

Hemorrhage,  although  scarcely  ever  profuse,  is  of  frequent  occur- 
rence, since  slight  injury,  as  from  syringing  or  probing,  may  wound 
the  growth ;  indeed  they  very  often  bleed  without  any  assignable 
cause. 

Although  caries  and  necrosis  can  scarcely  be  considered  as  due  to 
polypi  alone,  yet  when  the  bone  is  already  affected,  an  extension  of 
the  process  may  be  thus  brought  about. 

Meningitis  sometimes  occurs,  as  a  consequence  of  the  pressure 
caused  by  the  impaction  which  takes  place  when  acute  middle  ear 
inflammation  supervenes  during  the  presence  of  a  polypus  in  the 
tympanum.  The  writer  has  met  with  instances  of  this  kind,  one  of 
which,  at  least,  was  fatal.  In  these  cases  the  tumor  itself  seems  to  be 
increased  in  size.  In  one  case  where  a  patient  came  to  the  infirmary 
suffering  from  pain,  insomnia,  and  other  symptoms  due,  it  was  sup- 
posed, to  pachymeningitis,  relief  was  afforded  by  removing  a  large 


AUKAL  POLYPI.  309 

amount  of  polypoid  growth  from  the  tympanum  and  antrum  mas- 
toideum  ;  recovery  was  slow,  and  though  the  patient  was  finally  dis- 
charged, his  mind  at  the  time  was  affected.  In  still  another  case, 
where  the  patient  refused  to  submit  to  an  operation  for  removal  of  a 
polypus  which  troubled  him,  pachymeningitis,  believed  to  be  due  to 
the  pressure  of  the  polypus  upon  the  tegmen  tympani,  developed, 
with  hallucinations,  suicidal  mania,  etc.  The  patient  died  soon 
afterwards  from  maniacal  exhaustion. 

The  following  cases  illustrate  well  the  history  and  course  of  the 
disease. 

Measles.  Otitis  media  purulenta  chronica.  Otalgia.  Brain 
fever.     Polypus  in  both  ears. 

Female  child,  aged  11  years.  Seven  years  previously  had  measles, 
followed  by  frequent  attacks  of  otalgia.  Eighteen  months  since  she 
had  had  "  brain  fever  "  for  three  weeks,  with  discharge  from  the 
left  ear,  which  still  continues.  Three  weeks  ago  the  right  ear  also 
began  to  discharge,  without  previous  or  subsequent  pain. 

Examination  showed  a  polypoid  growth  in  the  left  tympanum. 
In  the  right  ear  a  polypus  was  seen  attached,  seemingly,  to  the  short 
process  of  the  malleus,  and  rendering  the  drum-head  indistinguishable. 

Measles.  Otitis  Media  Purulenta  Chronica.  Neuralgia.  Auto- 
phonia.     Tinnitus.     Catarrh  of  the  upper -air  Passages. 

Irish  domestic,  aged  16  years.  During  an  attack  of  measles  two 
years  ago  she  took  cold,  otitis  media  purulenta  of  the  left  ear  ensuing. 
jDischarge  continues  until  the  present  time,  accompanied  by  great 
deafness.  One  year  ago,  during  the  winter,  she  contracted  a  bad 
cold  by  going  out  of  the  house  with  bare  feet.  Since  then  there  has 
been  almost  constant  pain,  occasional  tinnitus  in  both  ears,  and 
weekly  neuralgic  headaches.  No  vertigo,  but  occasional  autophonia. 
Patient  is  subject  to  attacks  of  naso-phai'yngeal  catarrh.  There 
has  never  been  any  discharge  from  the  right  ear.  Menses  are  regu- 
lar and  normal,  and  general  health  fair.  Examination  shows  a  poly- 
pus occluding  the  left  external  auditory  canal  to  the  orifice.  This 
polypus  was  removed  with  the  snare,  and  daily  insufflations  of  boracic 
acid  ordered.  Improvement  in  hearing  followed  this  procedure,  and 
the  chronic  suppurative  process  healed  shortly  under  this  treatment. 

Treatment.  From  the  cases  presented  it  will  be  seen  that  escha- 
rotics  are  not  employed,  but  that  when  the  growth  is  of  sufficient 
size  to  be  engaged  in  the  loop  of  the  aural  snare,  that  instrument  is 
always  first  employed.  The  first  steps  to  be  taken,  however,  are  to 
lightly  syringe  the  ear,  and  afterwards  carefully  dry  the  parts  with 
absorbent  cotton-wool  wound  on  the  end  of  a  carrier;  then  ascertain, 
if  possible,  by  careful  probing,  the  exact  point  of  attachment 
of  the  pedicle,  since  most  aural  polypi  are  pediculated.  Gentle- 
ness is  urged  in  the  above  procedure,  for  polypi  bleed  very  readily 


310  AURAL   POLYPI. 

when  handled,  and  the  presence  of  blood  interferes  with  the  opera- 
tion. The  loop  of  the  polypus  snare  should  be  made  large  enough 
to  just  pass  over  the  tumor  and  then  be  slowly  carried  down  to  the 
seat  of  attachment,  when  the  wire  should  be  tightened  as  much  as 
possible  without  breaking. 

•  Fibroid  polypi  will  generally  resist  the  cutting  action  of  the  fine 
wire  now  generally  employed,  on  account  of  its  hardness,  in  place 
of  the  stouter  silver  wire;  it  will  be  well,  therefore,  when  it  is  evident 
that  the  wire  will  make  but  little  or  no  impression,  to  make  firm  trac- 


Fio.  48.— The  Author's  Polypus  Snare. 

tion  upon  the  tumor  and  complete  the  operation  by  evulsion.  In 
such  cases  it  will  usually  be  found  that  none  of  the  tumor  is  left. 

Mucous  polypi  are  most  easy  of  amputation.  Sometimes  several 
efforts  will  be  necessary  before  the  entire  mass  is  brought  away.  When 
any  portion  is  left,  it  should,  as  a  rule,  be  removed  by  the  biting 
forceps  or  a  cutting  curette.  Where  several  polypi  exist  in  the  same 
canal,  they  should  all  be  removed  at  one  sitting  if  the  patient  can 
endure  so  much,  for  anesthetics  are  seldom  employed  in  this  opera- 
tion, unless  it  be  in  the  case  of  children  or  for  the  detachment  of 
fungoid  tissue. 

Hemorrhage  is  rarely  profuse  after  the  operation,  but  when  it 
occurs  it  may  be  promptly  checked  by  gentle  syringing  with  hot 
water. 


AURAL    POLYPI.  311 

After  the  removal  of  polypi,  the  writer  has  found  by  experience 
that  it  is  not  necessary  to  use  such  severe  measures  as  the  applica- 
tion of  strong  caustics  to  the  base  from  which  the  tumor  sprung. 
Superficial  caustics,  as  a  rule,  are  inefficient,  while  searching  ones 
cannot  be  controlled  and  may  produce  serious  trouble  in  surrounding 
structures.  The  parts  should  after  every  operation  be  dressed  by 
insufflation  of  pulverized  boracic  acid  or  salicylic  acid.  In  certain 
cases  the  employment  of  alcohol  after  the  operation  is  beneficial. 
Strong  alcohol  may  be  instilled,  several  drops  at  a  time,  and  allowed 
to  remain  for  a  few  minutes.  It  may  be  applied  several  times  daily, 
and  in  some  instances  the  parts  do  well  if  afterwards  dressed  with 
one  of  the  powders  above  mentioned. 

Fungosities  springing  up  from  the  external  auditory  canal  where 
a  communication  exists  with  diseased  mastoid  tissue  should  be  re- 
moved with  the  biting  forceps  and  the  canal  afterward  dressed  with 
powdered  boracic  or  salicylic  acid.  This  dressing  should  be  repeated 
daily  by  the  surgeon  himself,  and  by  the  patient  during  the  interval 
until  the  improvement  begins,  when  the  application  may  be  made 
less  frequently. 


CHAPTEE  XV. 

FACIAL  PARALYSIS  DUE  TO  AFFECTIONS  OF  THE  EAR 
AND  CONTIGUOUS  PARTS. 

Bell's  palsy,  as  this  affection  has  also  been  called,  is  a  not  infre- 
quent sequence  of  disease  of  the  facial  nerve  in  its  passage  through 
the  temporal  bone.  It  may  be  caused  by  intercranial  disease  either 
at  the  source  of  the  nerve  or  at  some  point  along  its  course  before 
entering  the  temporal  bone;  by  necrosis  of  the  labyrinth;  by  inflam- 
mation of  the  middle  ear  near  which  the  facial  canal  passes  in  its 
course,  and  by  exposure  of  the  nerve  to  cold  after  its  exit  from  the 
stylo-raastoid  foramen.  Facial  paralysis  may  also  arise  from  trauma, 
fracture  of  the  base  of  the  skull,  etc.  Allusion  to  this  trouble  has 
been  made  in  discussing  acute  and  chronic  inflammation  of  the  middle 
ear,  syphilis,  etc. 

The  author  has  records  of  32  cases  seen  in  his  own  practice,  21 
males  and  11  females.  The  two  youngest  were  males,  aged  6  and 
7  months  respectively ;  two  males  and  one  female  were  2  years  of 
age,  and  one  female  was  under  3  years  of  age.  Five  patients  were 
between  5  and  10  years  of  age;  three  were  between  10  and  20;  seven 
were  between  20  and  30;  four  between  30  and  40;  five  between  40  and 
60,  and  two  between  50  and  60. 

Etiology.  In  sixteen  of  the  author's  cases  paralysis  of  the  facial 
occurred  during  the  existence  of  acute  inflammation  of  the  middle 
ear;  in  seven  cases  during  the  progress  of  chronic  purulent  inflam- 
mation of  the  middle  ear,  either  as  a  sequence  of  an  acute  exacerba- 
tion of  the  inflammation  or  due  to  exposure,  draughts  of  cold  air, 
etc.;  two  occurred  in  connection  with  subacute  inflammation  of  the 
middle  ear  from  exposure;  one  was  due  to  gunshot  wound  of  the 
drum  (see  case  of  Lieut.  Simms,  p.  154),  and  one  to  fracture  of  the 
base  of  the  skull,  causing  also  purulent  inflammation  of  the  middle 
ear.  Syphilis  was  the  cause  in  four  cases;  in  none  of  these  was  there 
any  purulent  process  or  caries  of  the  bone,  the  paralysis  being  due 
to  central  disturbance  or  perineuritis  of  the  facialis. 


FACIAL   PAKALT8I8.  313 

The  impaction  of  polypi,  owing  to  swelling  of  the  mucous  mem- 
brane about  the  growths  themselves,  and  possibly  to  their  enlarge- 
ment also,  seemed  to  have  been  causative  in  a  greater  or  less  degree 
in  five  cases.  Caries  and  necrosis  of  the  bone  accompanied  in  nu- 
merous instances  the  inflammatory  processes  of  the  middle  ear; 
in  eleven  cases,  namely,  there  was  caries  of  the  mastoid,  in  three 
there  was  caries  of  the  tympanic  and  auditory  plates.  In  five  cases, 
furthermore,  necrosis  of  the  labyrinth  occurred,  in  three  of  which 
the  cochlea,  as  shown  by  the  sequestra,  was  involved. 

Diseased  teeth,  especially  the  retention  of  teeth  which  had  been 
filled  after  destroying  the  pulp  or  "nerve,"  and  the  difficult  eruption 
of  wisdom  teeth,  exerted  a  very  decided  influence  in  a  considerable 
number  of  cases ;  steaming  and  poulticing  the  ear  excessively  for 
the  relief  of  earache  was  the  predisposing  cause,  without  doubt,  in 
three  cases.  In  most  of  such  cases  the  immediate  excitant  was  ex- 
posure of  the  sensitive  region  about  the  ear  to  draughts  of  cold  air.  It 
would  seem,  namely,  that  where  the  nerves  are  made  over-sensitive 
by  excessive  poulticing,  reflected  irritation,  and  the  like,  or  from  pro- 
longed excitation  from  any  cause,  giving  rise  to  exhaustion,  the  sus- 
ceptibility to  neuritis  is  increased,  and  slight  exciting  causes  may 
give  rise  to  facial  paralysis.  In  regard  to  the  side  affected  in  the 
cases  above  enumerated,  the  following  observations  were  made.  Nine- 
teen were  affected  on  the  left  side,  eleven  on  the  right,  and  two  on 
both  sides.  Among  the  males  the  right  side  was  affected  in  ten, 
the  left  in  nine,  and  both  in  two  cases,  whilst  in  females  the  left  side 
was  affected  in  ten  and  the  right  in  one  case.  The  more  frequent 
occurrence  on  the  left  side  is  notable;  the  same  tendency  on  the  left 
side  is  also  noted  in  connection  with  chronic  non-purulent  inflamma- 
tion of  the  middle  ear  and  in  othaematoma. 

Symptoms  and  Course.  The  appearances  of  the  face  when  the 
functions  of  the  facial  nerve  have  been  impaired  are  well  shown  in 
the  accompanying  illustrations,  one  a  single  and  the  other  a  double 
facial  paralysis.  The  cases  cited  below  are  so  illustrative  that  a  de- 
tailed account  of  symptoms  may  be  omitted  here.  Attention,  how- 
ever, is  invited  to  the  nervous  and  acoustic  disturbances,  as  pain, 
vertigo,  neuralgia,  noises  in  the  ear,  and  autophony  which  were  pres- 
ent in  these  cases.  These  made  a  group  of  symptoms  as  puzzling  as 
those  known  under  the  unscientific  name  of  Meniere's  disease. 

The  degree  of  deformity,  depending  on  the  extent  of  injury  to  the 
nerve,  is  slight  in  some  cases,  and  detected  with  difficulty,  whilst  in 
other  instances  it  is  very  great.  The  writer  has  noted,  for  example, 
cases  where,  from  the  history,  the  trouble  was  unknown  to  the  patient 


314  FACIAL   PAKALY8I8. 

himself  although  existing  for  many  years.  The  patient,  however, 
usually  observes  the  peculiar  loss  of  motion  of  the  muscles  of  the  one 
aide  of  the  face  in  laughing,  whistling,  or  in  masticating  food,  etc. 
Where  the  paralysis  is  due  to  middle  ear  disease  affecting  the  facialis 
before  the  chorda  tympani  is  given  off,  there  will  be  found  a  partial 
loss  of  taste  in  the  anterior  two-thirds  of  the  tongue,  on  the  same 
side;  this  may  not  be  noticed  by  the  patient  until  his  attention  is 
directed  to  the  matter.  Where  the  cause  of  the  paralysis  is  central, 
we  may  find  that  the  patient  retains  the  ability  to  raise  the  eyebrows, 
since  the  temporo-facial  branch  supplying  the  occipito  frontalis  mus- 
cle has  its  origin  remote  from  the  roots  of  the  portio  dura.  Spasm  of 
the  facial  muscles  from  the  physiological  effects  of  strychnia  or  other 
cause  may  be  mistaken  for  facial  palsy;  the  writer  once  saw  a  case  of 
spasm  due  to  large  doses  of  nux  vomica,  in  a  patient  with  chronic  in- 
flammation of  the  middle  ear,  where,  before  the  real  cause  was  dis- 
covered. Bell's  palsy  had  been  suspected. 

The  course  of  facial  palsy  depends  on  the  nature  of  the  primary 
affection;  where  it  appears  in  the  course  of  an  otitis  media  of  a  mild 
type,  or  arises  from  cold  or  the  impaction  of  a  polypoid  growth,  the 
palsy  disappears,  as  a  rule,  very  soon.  Removal  of  the  cause  will 
usually  be  followed  by  the  disappearance  of  the  trouble.  In  a  con- 
siderable number  of  instances,  however,  recovery  is  incomplete,  and 
more  or  less  disfigurement  remains  during  life.  It  has  been  stated 
that  facial  paralysis  is  sometimes  due  to  intra-tympanic  pressure 
caused  by  polypi  or  pent-up  secretions;  in  two  cases  of  the  latter  ob- 
served by  the  writer,  the  symptoms  disappeared  after  evacuation  of 
the  fluids,  in  one  instance  through  the  drum-head,  and  in  the  other 
through  the  sac  of  a  tympano-mastoid  abscess.  In  another  case  due 
to  impaction  of  an  inflamed  polypus  in  a  broken  down  subject  suffer- 
ing from  an  exacerbation  of  chronic  purulent  inflammation  occasioned 
by  exposure,  the  auditory  plate  became  carious,  the  cochlea  was  exfoli- 
ated, and  came  away  in  a  sequestrum.  After  this,  recovery  was  rapid 
and  considerable  hearing  remained  for  musical  tones  and  conversation. 

The  following  cases  illustrate  the  symptoms,  course,  and  termina- 
tion of  the  trouble. 

Case  1.  —  Chronic  Purulent  Inflammation  of  the  Tympanic  Attic 
and  the  Mastoid  Antrum.  Exacerbation  from  Impaction  of  Polypus. 
Facial  Palsy.     Pachymeningitis .    Death. 

J.  G.,  a  merchant,  aged  46  years,  was  first  visited  at  his  residence 
on  June  3d,  1879.  Patient  gave  a  neuropathic  ("  malarial ")  history, 
and  was  suffering  from  nervous  exhaustion  due  to  the  strain  attend- 
ant on  a  series  of  unsuccessful  business  ventures  during  the  past  nine 
years.     He  has  had  a  discharge  from  the  left  ear  since  childhood,  and 


FACIAL    PARALYSIS.  315 

when  living  in  England  was  taken  by  his  father  to  London  to  see  Mr. 
Toynbee.  Of  late  years  a  ''fleshy"  growth  presenting  at  the  left 
meatus  has  been  noticed.  He  stated  that  fonr  weeks  ago  the  dis- 
charge ceased,  and  he  was  taken  with  severe  pain  in  the  ear,  extend- 
ing to  the  mastoid  process  and  side  of  neck  and  face.  About  ten 
days  ago  all  of  the  symptoms  increased  in  severity,  and  the  left  side 
of  the  face  became  paralyzed.  Leeches  and  poultices  were  applied 
without  giving  any  relief.  During  the  past  two  days  the  escape  of 
pus  and  blood  from  the  pharynx  seemed  to  point  to  drainage  through 
the  Eustachian  tube. 

Examination.  The  inner  extremity  of  the'  external  auditory  canal 
is  completely  occluded  by  an  impacted  polypoid  mass.  There  is  left 
facial  paralysis.  There  are  a  number  of  carious  teeth  in  the'  lower 
jaw,  together  with  a  heavy  collection  of  tartar.  He  complains  of 
photophobia  and  vertiginous  phenomena;  the  pulse  and  temperature 
are  almost  normal. 

Treatment.  The  polypus  was  removed  with  a  snare,  and  the  pa- 
tient was  placed  under  appropriate  constitutional  treatment.  During 
the  next  month  there  was,  however,  no  improvement  in  the  symp- 
toms, the  patient  continuing  to  lose  ground,  although  the  drainage 
from  the  ear  was  unobstructed.  There  were  at  times  severe  exacerba- 
tions of  pain  in  the  head  and  ear  with  vertigo  and  vomiting.  After 
the  twenty-seventh  day  the  patient  grew  rapidly  worse,  agonizing  pain 
in  the  head  and  vertigo  were  constant,  diplopia  and  muscular  spasms 
of  right  side  of  face  appeared;  he  was  unable  to  swallow  or  voluntarily 
empty  the  bladder,  became  comatose,  and  died  July  11th. 

In  this  case,  after  the  cerebral  symptoms  set  in,  and  after  estab- 
lishment of  free  drainage,  there  was  no  further  increase  of  the  inflam- 
mation of  the  middle  ear  tract,  nor  was  there  any  periostitis  externa. 

Case  2. — Facial  paralysis  of  the  right  side,  caused  hy  necrosis  of 
the  petrous  hone,  occurring  in  a  case  of  chronic  purulent  inflamma- 
tion of  the  middle  ear. 

See  Figs.  49  and  50  (from  photographs),  showing  the  patient  in 
repose,  and  the  same  patient  endeavoring  to  laugh. 

Patient  was  a  woman,  ]  9  years  of  age.  When  about  ten  years  old 
she  experienced  buzzing  in  the  right  ear.  Coming  for  treatment  in 
November,  1880,  she  stated  that  the  ear  never  discharged  until  six 
months  previously;  commencing  after ''pains  and  a  gathering"  in 
the  ear.  Four  months  ago  she  had  a  severe  cold  in  the  head,  and  one 
week  afterwards  she  found,  on  getting  up  in  the  morning,  that  the 
right  side  of  the  face  was  paralyzed;  the  mouth  was  drawn  to  the 
left,  and  she  was  unable  to  close  the  right  eye.  She  was  not  suffering 
pain  when  she  came  for  treatment,  but  previously  she  had  suffered 
much  from  neuralgia  in  the  right  temporal  region,  perhaps  partly 
from  dental  caries.  For  the  past  four  months  the  attacks  have  been 
of  a  more  distinctly  paroxysmal  character.  For  the  past  two  months 
she  was  never  free  of  vertigo,  and  was  in  constant  fear  of  falling 
backwards;  her  gait  is  staggering.  When  pressed  for  a  statement 
respecting  the  duration  of  the  aural  disease,  she  admitted  that  the  ear 
had  always  had  a  bad  odor. 


316 


FACIAL   PARALYSIS. 


On  examination,  a  large  polypus  was  seen  to  almost  fill  the  right 
external  auditory  canal,  and  the  probe  detected  the  presence  of  a 
detached  sequestrum  of  bone  deep  in  the  canal.  The  polypus,  which 
was  attached  to  the  superior-posterior  wall  of  the  canal,  near  its  outer 
extremity,  was  removed  by  the  snare,  and  the  sequestrum  was  imme- 
diately afterwards  brought  away  by  the  foreign-body  forceps.  The 
latter  came  away  with  difficulty,  although  the  external  auditory  canal 
was,  fortunately,  very  large.  The  sequestrum,  when  examined,  proved 
to  consist  of  a  plate  of  irregularly  rounded  bone  about  one-fourth  of 
an  inch  in  diameter,  one  portion  of  which  was  very  thin,  and  the 
other  nearly  a  quarter  of  an  inch  in  thickness.     This  sequestrum  con- 


FiQ.  49. 


Fig..  50. 


sists  proba-bly  of  the  roof  of  the  tympanum  and  a  portion  of  the 
mastoid  body  just  external  to  the  hiatus  Fallopii.  A  ridge  on  the 
specimen  corresponds  to  the  anterior  ridge  of  the  groove  on  the  supe- 
rior border  of  the  bone  located  beneath  the  superior  petrosal  sinus. 
The  reticulated  arrangement  in  the  cavity  of  the  specimen  has  the 
general  arrangement  of  the  reticulae  of  the  antrum  mastoideum;. 
besides  which,  the  relations  of  the  compact  and  cancellous  tissues  are 
such  as  to  exclude  its  having  been  located  elsewhere.  The  superior 
surface  of  the  sequestrum,  where  it  came  in  contact  with  the  dura 
mater,  was  roughened  by  caries. 

After  the  removal  of  the  sequestrum,  another  large  polypoid  mass 


FACIAL   PARALYSIS. 


317 


was  taken  away  from  the  ear,  leaving  a  very  large  cavity  at  the  junc- 
tion of  the  canal  and  the  posterior  wall  of  the  tympanum. 

At  the  bottom  of  this  cavity  was  a  mass  of  granulation  tissue, 
which,  under  the  use  of  powdered  acidum  boracicum,  soon  disap- 
peared, and  the  discharge  ceased.  The  facial  nerve,  when  tested,  did 
not  respond  to  either  galvanism  or  faradism,  although,  at  first,  the 
muscles  of  the  face  gave  degenerative  reaction. 

In  this  case,  the  facial  nerve  was  undoubtedly  impaired  before 
the  chorda  tympani  was  given  off,  for  there  was  very  decided  modi- 
fication of  the  sense  of  taste  on  the  right  side  of  the  tongue.  The 
palate  was  unaffected.  The  palsy  has  been  treated  by  the  galvanic 
current,  but  with  slight  improvement.  Hearing  was  not  entirely  lost. 
The  patient  is  at  present  free  of  vertigo  and  tinnitus  aurium,  but 
has  occasional  headaches,  owing  to  a  rather  run-down  condition, 
and  the  continuance  of  oral  and  naso-pharyngeal  irritation. 

Case  3'. — Bilateral  facial  paralysis  occurring  in  a  case  of  sudden 
deafness  fromir  syphilis. 


Fig.  51. 


Fig.  52. 


See  Figs.  51  and  52  (from  photographs),  showing  the  patient  in 
repose,  and  the  same  patient  endeavoring  to  close  the  mouth  and  eyes. 

'  Cases  3  and  3,  with  the  accompanying  illustrations,  were  published  in  The 
Illustrated  Quarterly  of  Medicine  and  Surgery,  Vol.  I.,  No.  1,  January,  1882, 


318  FACIAL   PAKALY8I8. 

This  patient  was  a  man,  40  years  of  age,  who  had  contracted  syphilis 
in  the  summer  of  1879.  and  was  treated  in  Charity  Hospital.  Three 
months  later,  having  taken  a  severe  cold,  he  had  paralysis  of  the 
right  side  of  the  face.  Three  months  after  this  attack,  and  six 
months  subsequent  to  the  syphilitic  infection,  he  was  again  very  much 
exposed  in  a  cold  rainstorm,  and  went  to  bed  with  a  severe  cold;  on 
getting  up  the  following  morning  he  experienced  so  much  vertigo 
that  he  could  only,  walk  with  difficulty.  While  eating  his  breakfast, 
he  found  that  he  could  open  his  mouth  only  wide  enough  to  admit  a 
spoon  between  his  teeth.  A  facial  paralysis  of  the  left  side  had  now 
occurred,  and  the  inability  to  get  food  into  the  mouth  was  owing, 
doubtlessly,  to  the  unique  employment  of  the  unaffected  muscles  used 
in  mastication. 

The  patient  at  this  time  experienced  severe  pains  in  the  right  side 
of  the  head.  Soon  after  the  experience  above  related,  as  taking  place 
at  breakfast,  while  trying  to  converse  with  a  friend,  he  found  himself 
to  be  perfectly  deaf  in  both  ears,  and  since  then  he  has  been  unable 
to  hear  a  single  word,  however  loudly  spoken.  The  patient  las  not 
conscious  of  any  deafness  following  the  first  attack  of  paraysis  on 
the  right  side. 

When  the  patient  first  experienced  difficulty  in  opening  the  mouth, 
he  fancied  that  he  had  "lock-jaw,"  and  he  then  ascertained  that 
instead  of  the  face  being  drawn  to  the  left,  both  sides  were  now 
alike.  Following  both  these  paralytic  invasions,  he  experienced  dis- 
tressing tinnitus  aurium,  which  continued  up  to  the  time  he  was 
seen — some  eighteen  months  after  the  initial  attack.  He  also  sulTered 
greatly  from  pains  in  the  head  and  vertigo  until  a  short  time  before 
the  writer  saw  him.  He  could  not,  of  course,  either  whisper  or 
whistle.     No  treatment  was  attempted. 

The  view  of  this  patient,  when  the  face  was  in  repose,  gives 
the  characteristic  facial  expression  in  this  affection;  the  eyes  have  a 
horridly  staring  look,  while  the  entire  face  is  an  expressionless  blank. 
When  trying  to  explain  the  symptoms  of  his  case,  the  difficulty  experi- 
enced in  enunciation,  together  with  the  nasal  tone  and  collapsing  of  the 
nostrils — the  latter  preventing  the  entrance  of  air  into  the  nose — 
caused  the  patient  to  exert  himself  in  a  most  painful  manner,  yet  the 
face  gave  no  evidence  of  the  struggle  taking  place.  The  absence  of 
nearly  all  of  the  teeth  rendered  articulation  still  more  difficult. 
When  an  effort  was  made  to  close  the  mouth  and  eyes,  the  former 
was  accomplished  by  the  action  of  the  temporal,  masseter,  and  inter- 
nal pterygoid  muscles;  the  patient  was,  however,  inclined  to  use  his 
hand  when  requested  to  bring  the  jaws  together.  It  was  not  possible 
to  close  the  eyes,  but  he  was  able  to  roll  them  upwards  and  inwards, 
the  lower  lid  remaining  inactive,  the  upper  lid  dropping  down  slightly 
by  its  own  weight;  the  effect  of  the  display  of  the  lower  portion  of 
the  cornea  between  the  widely  separated  lids  was  ghastly  in  the 


FACIAL    PARALYSIS.  319 

extreme.  Fortunately  for  these  cases,  the  levator  palpebrae  not  being^ 
supplied  by  the  facial  uerve,  the  upper  lid  can  be  raised  from  the  eye. 
The  cause  of  the  paralysis  in  this  case  is  somewhat  in  doubt. 
There  is  a  strong  probability  that  the  morbid  process  which  gave  rise 
to  it  was  at  the  base  of  the  brain;  if  so,  it  was  probably  syphilitic. 
The  fact  that  the  patient  had  lost  control  over  the  fronto-occipital 
muscle  pointed  to  a  central  lesion.  There  are  some  reasons,  however, 
for  believing  that  peripheral  causes  also  existed,  the  most  important 
being  the  aural  symptoms;  the  attacks  followed  colds,  during 
which  there  were  pains  in  the  neighborhood  of  the  ear  and  disturb- 
ances of  the  functions  of  both  the  transmitting  and  perceptive  regions 
of  the  ear.  The  exact  seat  of  the  peripheral  lesion,  if  any,  cannot  be 
told,  for  there  were  but  slight  morbid  changes  in  the  ear  perceptible 
to  the  eye,  and  the  patient  did  not  return  again  to  have  the  sense  of 
taste,  etc.,  tested.' 

Case  4.^ — Complete  facial  paralysis  occurring  during  an  attach  of 
subacute  catarrhal  inflammation  of  the  middle  ear.  Severe  head  cold. 
Irritation  from  a  dead  tooth. 

Patient  was  a  seminarian,  40  years  of  age,  who  had  always  been 
subject  to  head  catarrh  and,  of  late  years,  to  neuralgia  from  irritation 
of  defective  teeth.  General  health  not  good.  His  present  trouble 
began  about  four  months  ago,  when  the  amalgam  plug  in  the  lower 
right  second  bicuspid  tooth  became  loose,  and  was  replaced  by  a 
dentist  after  the  pulp  and  nerve  had  been  removed  from  the  tooth, 
leaving  it  in  a  diseased  and  sensitive  condition.  Patient  was  much 
run  down  at  the  time  by  hard  work.  On  Christmas  morning  he  got 
up  feeling  badly  from  an  exacerbation  of  head  catarrh.  During  the 
church  service  he  perspired  freely  under  the  heavy  vestments  worn, 
and  stood  in  a  draught  of  cold  air  from  an  open  window  with  uncov- 
ered head  and  right  side  of  neck.  An  attack  of  subacute  aural 
catarrh  followed  this,  and  severe  neuralgic  pains,  starting  in  the  right 
mastoid  and  extending  down  the  neck  and  over  the  temporal  region. 
On  the  second  day  after  this,  complete  facial  paralysis  of  the  right 
side  developed.  Pain  in  the  right  mastoid  was  so  severe  as  to  mask 
other  symptoms,  and  patient  was  confined  to  his  bed  for  three 
weeks.  For  several  weeks  after  getting  up  the  paralysis  was  treated 
with  the  faradic  and  galvanic  currents,  and  the  ear  blistered. 

The  author  first  saw  the  patient  about  three  months  after  the 
trouble  began.  Patient  was  then  weak  and  nervous,  and  very  con- 
siderable paralysis  of  all  the  muscles  of  expression  remained.  From 
the  first  there  has  been  considerable  swelling  on  the  jaw  over  the 
region  of  the  dead  tooth,  and  hyperaesthesia  of  the  skin  of  right 
cheek.     The  drum-heads  showed  but  little  of  the  effects  of  the  recent 

^  For  other  features  of  this  case,  especially  as  regards  the  hearing,   see 
American  Journal  of  Otology,  vol.  ii.,  p.  304. 
»  Medical  Record,  June  19th,  1886. 


3'20  FACIAL   PARALT8I8. 

catarrhal  inflammation.     Hearing  in  right  ear  almost  normal;  but  in 
the  left  only  loud  voice  was  heard. 

On  extraction,  the  tooth  giving  rise  to  the  irritation  of  the  inferior 
dental  nerve  was  found  to  have  its  pulp-cavity  carelessly  filled  with 
amalgam,  its  canal  being  loosely  packed  with  cotton-wool  down  to 
within  a  quarter  of  an  inch  of  the  apex.  The  alveolus  was  in  a  state 
of  inflammation. 

The  anomalies  of  audition  were  particularly  interesting,  owing,  it 
is  believed,  to  the  paralysis  of  the  tensor  tympani,  stapedius,  and 
tensor  palati  muscles,  which  derive  their  motor  nerves  from  the 
facial,  since  it  is  through  these  muscles  that  tension  of  the  transmit- 
ting mechanism  of  the  ear  is  maintained.  Since  the  paralysis  came 
on,  his  own  voice  is  unnatural  to  himself  ;  it  echoes  in  the  right  ear. 
Sounds  emitted  from  the  movements  of  heavy  trucks,  coal  rattled  in 
a  sheet-iron  vessel,  the  larger  pipes  of  an  organ,  etc.,  give  rise  to  a 
second  impression  of  sound  which  is  perceived  in  another  key  al- 
together, and  resembles  the  rattle  of  the  cords  of  a  snare-drum. 
This  supplementary  phenomenon,  known  as  acousis  duplicata,  or 
double  hearing,  is  due  to  cognizance  being  taken  of  vibratory  move- 
ments of  the  drum-head  itself,  which  occur  independently  of  the  rest 
of  the  transmitting  mechanism,  i.  e.,  without  causing  excursive  move- 
ments in  the  chain  of  ossicles.  Autophonous  phenomena  were  experi- 
enced in  the  left  ear,  due  to  the  loss  of  tension  from  cicatricial  trans- 
formation. 

On  reviewing  the  history  of  this  case  it  would  seem  that  the 
nerves  affected  by  the  deatal  irritation  were  in  an  exhausted  state, 
favorable  to  neuritis,  and  that  the  facial  nerve,  which  lies  in  the 
inner  wall  of  the  tympanum,  was  especially  liable  to  become  affected 
through  extension  of  the  inflammation  of  the  middle  ear  present. 
It  is  difficult  to  say  whether  the  exposure  to  the  draught  of  cold  air 
or  the  middle-ear  disturbance  first  gave  rise  to  the  nervous  trouble ; 
in  other  words,  we  cannot  tell  whether  it  was  an  ascending  or  de- 
scending neuritis.  It  seems  probable,  however,  that  but  for  the 
presence  of  the  dead  tooth  the  patient  might  have  escaped  the  facial 
paralysis,  since  non-suppurative  inflammation  of  the  middle  ear  is 
not  liable  to  extend  itself  to  the  facial  nerve ;  even  the  much-exposed 
chorda  tympani  seems  seldom  to  be  affected.  There  was  in  this  case 
no  alteration  in  the  sensation  of  the  tongue. 

We  are  not  left  in  doubt  as  to  the  peripheral  origin  of  the  paralysis 
in  this  case,  since  the  temporo-facial  branch  supplying  the  occipito- 
frontalis  muscle  was  involved,  and  its  fibres  are  believed  to  have  a 
central  origin,  remote  from  the  other  roots  of  the  portio  dura. 


FACIAI.    PARALYSIS.  321 

The  value  of  pain  in  the  mastoid  as  a  symptom  in  differential 
diagnosis  is  well  shown  here.  Intense  and  prolonged  pain  was  ex- 
perienced, due  to  the  neuritis  alone,  in  all  probability,  and  hence  the 
operation  of  trephining  the  mastoid  for  the  relief  of  inflammation  of 
the  antrum  or  cellules  would  have  been  inadvisable. 

The  following  case  is  one  showing  great  similarity  with  the  fore- 
going : 

Case  5. — Facial  Paralysis  due  to  severe  Head  Cold  as  an  exciting 
Cause,  and  the  great  Irritation  from  a  "  dead  "  Tooth.  Chronic  Catar- 
rhal Otitis     Media.  Syphilis.     Recovery  from  palsy  in  fourteen  days. 

Patient,  a  male,  aged  27  years,  with  good  general  healtli,  was  first 
seen  by  the  author  on  October  17th,  1887.  Patient  had  suffered  for 
two  months  in  1882  with  severe  bronchial  catarrh,  and  had  always 
been  afflicted  with  catarrh  of  the  head.  He  has  been  slightly  deaf 
for  several  years,  but  three  years  ago  the  deafness  became  especially 
marked  in  the  left  ear.  Two  years  ago  he  contracted  syphilis,  and 
was  kept  for  a  whole  year  under  full  doses  of  mercury  at  the  point  of 
salivation.  His  teeth  have  long  been  defective.  One  year  ago  a 
"dead  tooth,"  the  left  upper  first  bicuspid,  was  filled  by  a  dentist. 
About  four  months  since  a  sudden  "roaring  noise"  began  in  the  left 
ear,  after  a  sea-bath,  and  has  continued  ever  since.  This  was  treated 
by  vigorous  syringing  of  the  ear  two  or  three  times  daily.  Two 
weeks  ago  he  began  to  experience  a  giddy  feeling  at  times,  with 
nausea  ;  he  fell  from  his  chair  at  the  table  one  day.  Since  this  time 
he  has  also  experienced  headaches  in  the  left  side,  extending  over  the 
forehead  of  the  same  side,  and.  furthermore,  an  occasional  pain  in  the 
left  ear.  Three  days  ago,  whilst  at  sea,  took  a  severe  head  cold  from 
exposure.  He  states  that  the  cold  settled  about  the  angle  of  jaw  under 
left  ear.  The  left  facial  palsy  was  first  noticed  yesterday.  He  cannot 
spit,  close  the  left  eye,  or  whistle.  Mouth  drawn  to  right  side.  There 
is  very  decided  head-catarrh.  Patient  is  much  run  down  in  health, 
and  vertiginous.  Tinnitus  annoys  him  greatly.  Hearing  in  left  ear 
for  loud  voice  only  at  five  feet  distance ;  in  right  almost  normal.  The 
region  above  the  angle  of  jaw  and  under  auricle  on  left  side  are  sensi- 
tive to  the  touch.    To  have  "  dead  "  tooth  removed. 

October  18th. — Had  "dead"  tooth  drawn  yesterday,  both  roots 
being  found  diseased,  with  an  abscess  in  the  jaw.  Another  carious 
and  filled  tooth,  on  the  right  side,  was  also  removed.  Pain  about  the 
angle  of  jaw  very  severe  to-day. 

October  19th. — Pain  and  tenderness  now  well  realized  at  the  exit 
of  the  facial  nerve  from  its  canal.  Patient  did  not  obtain  any  sleep 
during  the  past  night.  During  the  exacerbation  of  pain  the  paralysis 
seems  to  be  increased. 

Veratrine  ointment  ordered,  and  5  grains  of  quinine  every  after- 
noon. 

October  20th. — Pain  less,  as  is  also  the  paresis.     Slept  well  last 
night.    The  hearing  in  the  left  ear  has  improved  somewhat.    Calcium 
sulphide  and  tinctura  ferri. 
21 


322  FACIAL   PARALYSIS. 

October  22d.  —No  paiu.  Paralysis  the  same.  There  is  some  con- 
gestion of  the  conjunctiva  of  left  eye. 

October  24th. — General  condition  improved.  Conjunctivitis  much 
less. 

October  26th. — Palsy  almost  gone.  Some  slight  amount  of  tender- 
ness still  remains  at  the  angle  of  jaw  on  left  side  and  under  auricle. 
His  general  health  has  improved  greatly,  and  the  slight  vertigo  felt 
occasionally  up  to  this  time  has  disappeared. 

October  29th. — Great  improvement  in  condition.  Palsy  almost 
absent. 

October  Slst. — Palsy  entirely  gone.  No  pain  or  tenderness  in  or 
about  auricle  and  jaw.    The  tinnitus  now  resembles  "escaping  steam. ^ 

Prognosis.  In  a  large  number  of  instances  this  is  favorable.  In 
the  32  cases  observed  by  the  author  the  termination  was  as  follows  : 
In  4  cases  recovery  took  place  in  from  a  few  days  to  two  weeks  ; 
6  recovered  in  from  three  weeks  to  two  months  ;  5  recovered  in 
from  two  to  three  months ;  2  inside  of  one  year ;  2  inside  one  year 
and  a  half.  The  result  was  unknown  in  8  cases,  and  5  cases  died 
from  the  effects  of  the  aural  trouble. 

Of  the  4  syphilitic  cases  the  palsy  was  double  in  2  and  perma- 
nent ;  in  1  there  was  great  improvement,  in  the  other  the  result  is 
unknown.  Of  the  3  cases  of  cochlear  exfoliation  1  gradually 
recovered  in  the  course  of  eighteen  months;  1  improved  greatly 
and  the  other  but  slightly. 

The  distortion  of  infantile  palsy  usually  disappears  as  age  advances, 
but  in  some  cases  it  remains  to  more  or  less  extent  through  life. 

Treatment.  Our  attention  should  first  be  directed  to  the  cause. 
It  goes  without  saying  that,  in  addition  to  the  treatment  of  the  ear 
itself,  polypi,  sequestra,  granulation  tissue,  pent-up  secretions,  or  any 
foreign  body  in  the  tympanic  cavity  should  be  sought  for  and 
promptly  removed.  In  the  writer's  experience,  oral  irritation  often 
stands  in  the  relation  of  a  remote  or  indirect  cause,  and  the  happiest 
effect  has  often  been  observed  to  follow  the  extraction  of  a  wisdom 
tooth  (usually  the  lower  one  on  the  same  side),  the  eruption  of  which 
is  difficult,  or  a  tooth  the  pulp  of  which  has  been  destroyed  and 
afterwards  filled.  For  the  pain  about  the  mastoid  and  down  the  side 
of  the  neck  or  in  the  temporal  region,  the  application  of  veratrine 
ointment,  used  several  times  a  day,  is  often  beneficial.  Usually  the 
employment  of  the  bisulphate  of  quinine  or  the  tincture  of  the  chlor- 
ide of  iron  is  indicated.  The  writer  prefers  to  give  the  former  in 
from  one  to  three  grain  doses,  three  or  four  times  daily  ;  the  latter  in 
elixir  simplex,  as  a  menstruum,  in  doses  of  five  drops,  well  diluted  in 
water,  after  meals.     The  importance  of  out-door  exercise  and  other 


FACIAL   PARALYSIS.  323 

hygienic  measures  is  to  be  kept  in  mind.  Poultices  and  steaming  are 
to  be  avoided  as  a  rule,  since  we  find  that  their  excessive  employment 
has  been  the  principal  predisposing  cause  of  facial  palsy  in  several  in- 
stances. Electricity  has  been  highly  vaunted  in  such  cases,  but  the 
author  has  never  been  convinced  of  the  advantages  claimed  to  arise 
from  the  employment  of  this  agent.  For  the  neuritis  itself  the  gal- 
vanic current  is  recommended,  and  for  the  restoration  of  power  to 
the  facial  muscles  the  faradic  current  is  employed.  This  latter  has, 
it  is  tliought,  been  of  advantage  in  some  instances.  It  has  been  re- 
commended to  hold  the  affected  side  of  the  face  in  position  by  insert- 
ing a  wire  bit,  shaped  like  a  fish  hook,  in  the  corner  of  the  mouth, 
tension  being  maintained  by  attaching  the  bit  to  the  auricle  of  the 
corresponding  side  of  the  head.  This  may  be  attended  with  more  or 
less  comfort  to  the  patient,  but  we  must  not  forget  that  any  measure 
interfering  with  the  action  of  the  muscles,  like  the  use  of  shoulder 
braces,  weakens  them  from  disuse,  rather  than  strengthens  them. 

Central  lesions  cannot  well  be  reached,  though  in  syphilis  the 
remedies  suggest  themselves  to  every  one,  namely,  the  mercurials  and 
iodide  of  potassium.  The  author's  practice  is  to  give  these  remedies 
in  much  smaller  doses  than  are  usually  employed. 


CHAPTER  XVI. 

ANOMALIES   OF  AUDITION. 

Noises  in  the  ear.  Autophonia,  pseudacousma  or  false  hearing.  Effects  of 
false  hearing  on  Singers,  Actors,  Lecturers  and  Musicians.  Certain  other 
anomalies  of  audition.  Dysacousma  or  painful  hearing.  Some  of  the  rela- 
tions of  certain  aural  phenomena,  hallucinations,  etc.,  to  Insanity  and 
Brain  Affections. 

If  we  accept  the  conclusions  that  seem  fairly  admissible  from  a 
study  of  the  anatomy  of  the  sound-transmitting  mechanism  of  the 
ear,  the  performance  of  its  normal  physiological  functions,  and  its 
anomalous  action  under  the  pathological  conditions  described  some- 
what fully  in  another  place  (see  Parti.),  we  shall  find  ourselves  at 
variance  with  the  views  held  by  some  writers  respecting  the  part  per- 
formed by  the  transmitting  media  of  the  middle  and  inner  ear 
respectively.  Further  scientific  research  may,  of  course,  increase  our 
knowledge  of  this  subject,  and  the  writer  cannot,  therefore,  presume 
to  advance  any  hypothesis  as  other  than  tentative.  It  is  believed, 
however,  that,  in  consequence  of  misleading  physiological  theories, 
whereby  pathological  acoustic  phenomena — due  to  disturbances  in  the 
middle  ear — have  been  relegated  to  the  labyrinthine  or  cochlear 
mazes  of  the  inner  ear,  progress  in  the  field  of  aural  clinical  research 
has  been  much  retarded. 

The  auditory  nerve  is  considered  by  physiologists  as  belonging  to 
the  class  of  nerves  having  special  functions,  and  as  being  in  the  ordi- 
nary sense  in  no  way  either  sensory  or  motor.  It  is  doubtlessly 
specially  adapted  to  the  mode  of  motion  which  sound  assumes  in  the 
course  of  transmission  from  the  middle  ear  to  the  perceptive  centre 
of  the  brain,  or  auditory  tract ;  but  it  is  well  known  from  clinical  ex- 
perience that  irritation  of  the  middle  ear,  as  in  operations  upon  this 
region,  or  the  injection  of  water,  even  when  the  drum-head  is  intact, 
or  from  impressions  propagated  in  some  remote  region  of  the  body, 
and  transmitted  along  the  course  of  the  facial,  chorda  tympani,  or 
other  nerves,  may  give  rise  to  vertiginous  phenomena.     The  terminal 


ANOMALIES   OF   AUDITION.  325 

filaments  of  the  portio  mollis  doubtlessly  seldom  take  cognizance  of 
impressions  other  than  those  due  to  aerial  impact  of  sound  normally 
transmitted.  Yet  as  we  all  know,  sound  is  but  force  in  motion,  and 
when  the  middle  ear  mechanism  is  absent  or  defective,  its  impulses 
may  give  rise  to  cerebral  shock.  Indeed,  it  is  probable  that  an  anaemic 
condition  of  the  individual  may  lessen  the  drum's  tension,  as  in  sea- 
sickness and  the  like,  so  that  oscillations  of  the  drum-head,  occasioned 
by  heavy  sounds  imparted  from  the  motions  of  the  waves  and  the 
ship,  would  give  rise  to  dizziness  and  other  phenomena. 

The  mode  of  sound  transmission,  where  hearing  does  not  take  place 
through  the  transmitting  mechanism  of  the  middle  ear,  or  does  so 
imperfectly,  is  of  the  greatest  interest  to  otologists.  In  normal  hear- 
ing it  would  not  seem  to  be  transmitted  by  means  of  molecular 
changes  in  the  osseous  tissues  of  the  chain  of  ossicles,  since  they 
do  not  offer  an  unbroken  continuity;  but  it  may  reach  the  perceptive 
centre  through  the  walls  of  the  drum  or  even  from  the  tissues  of  the 
head  from  all  directions,  as  for  example,  when  a  vibrating  tuning- 
fork  is  held  in  contact  with  the  skull  or  teeth.  The  sensory  nerves 
of  all  parts  of  the  body  likewise  convey  to  the  brain  vibratory  sensa- 
tions, but  such  impressions  are  described  as  being  usually  felt  only, 
unless  the  undulating  movements  are  taken  in  some  degree  by  the 
transmitting  mechanism  of  the  middle  ear.  Advantage  may  be  taken 
of  this  fact  to  aid  the  defective  hearing  sense  by  means  of  a  vibrating 
fan  or  the  like  held  against  the  teeth.- 

In  respect  to  the  significance  of  the  transmission  of  sound  to  the  ear 
through  the  tissues  in  aural  disease,  it  may  be  said  that  so  long  as  the 
parts  of  the  ear  concerned  in  sound  transmission  remain  in  a  normal 
state,  sound  almost  exclusively  reaches  the  auditory  nerve  by  means 
of  their  action,  and  since  impulses  of  sound  are  thus  practically  ex- 
cluded from  all  other  channels  (tissues)  of  transmission,  the  confu- 
sion which  would  otherwise  arise  is  avoided. 

Disease,  however,  may  give  rise  to  changes  in  the  transmitting 
mechanism,  owing  to  which  vibratory  impulses  are  but  imperfectly 
conveyed  in  the  natural  way,  i.  e.,  by  aerial  conduction,  and  then  it 
is  that  the  auditory  nerve  takes  cognizance  of  sounds  hitherto  ex- 
cluded from  it  by  the  peculiar  arrangement  of  the  transmitting  appa- 
ratus; these  unpleasant  and  strangely  sounding  undulatory  vibrations 
are  received  through  the  osseous,  muscular,  and  other  tissues,  the 
contents  of  the  blood-vessels,  and  the  Eustachian  tube  when  patulous. 

The  altogether  anomalous  hearing,  which  may  exist  for  a  time  con- 
tinuously, or  may  be  interrupted,  as  it  were,  by  almost  normal  hear- 
ing, is  dependent  for  the  most  part  on  the  passage  of  sound  to  the  ear. 


326  ANOMALIES    OF    AUDITION. 

through  both  aerial  and  tissue  media  at  the  same  moment.  Owing 
to  the  increased  intensity  of  sound,  thus  partly  heard  coming  through 
the  conducting  medium  of  the  tissues,  an  extremely  confusing  and 
disagreeable  effect  is  produced,  and  the  definition  of  an  exclusively 
aerial  transmission  is  wanting. 

As  is  well  known  to  otologists,  hearing 'may  thus  become  a  very 
painful  experience;  if  the  patient  then  hears  his  own  voice  autopho- 
nously,  he  feels  that  it  has  been  much  altered,  or  is  not  intelligible 
to  others;  indeed,  it  is  almost  unrecognizable  to  himself  even.  The 
discomfort  may  be  increased,  if  such  a  thing  be  possible,  where  the 
physical  and  mental  distress  is  almost  unbearable,  by  the  tinnitis 
aurium  arising  from  the  circulatory  movements  taking  place  near 
enough  to  the  ear  to  be  heard.  Loud  noises,  such  as  the  passage  of 
railway  trains,  street  trucks,  the  action  of  machinery  or  the  like, 
owing  to  the  better  transmission  of  their  more  profound  impulses 
through  unaccustomed  media  of  approach,  fall  upon  the  nervous  cen- 
tre of  audition  like  a  blow,  and  thus  give  rise  to  dysacousma. 

It  being  doubtful  if  the  perceptive  sense  of  hearing  be  increased  by 
labyrinthine  inflammation,  we  may  suppose  that  so-called  hyperaes- 
thesia  of  the  auditory  nerve  consists  in  the  painfulness  of  the  impres- 
sion made  by  sound  on  the  perceptive  centre.  If  this  be  true,  in- 
flammation of  the  perceptive  filaments  of  the  auditory  nerve  in  the 
labyrinth  alone  would  scarcely  be  expected  to  increase  the  hearing 
power.  On  the  other  hand,  it  would  be  diflicult  to  determine  what 
degree  of  labyrinthine  inflammation  was  necessary  to  impair  the  per- 
ceptive functions.  Labyrinthine  inflammation,  viewed  from  a  clini- 
cal point  of  view,  is  doubtlessly  nearly  always  consecutive  to  middle 
ear  disease,  but  whether  existing  independently  or  in  conjunction 
with  middle  ear  trouble,  the  transmission  of  sound  would  be  more 
effectively  performed  by  means  of  aerial  conduction  as  regards  intel- 
ligible perception.  In  middle  ear  disease,  however,  the  tuning-fork 
would  be  better  heard  through  the  tissues  inversely  to  an  increasing 
defect  in  aerial  transmission,  but  not  necessarily  better  heard,  how- 
ever, on  account  of  labyrinthine  defects. 

Even  if  the  auditory  filaments  were  alone  affected,  the  tuning-fork 
would  be  best  heard  by  aerial  conduction,  since  the  transmitting  ap- 
paratus affords  the  better  conduction,  and  at  the  same  time  interferes 
with  osseous  conduction.  But  recognizable  cases  of  labyrinthine  dis- 
ease alone  are  rare,  and  it  is  difficult  to  establish  the  fact  that  no 
middle  ear  disease  co-exists  in  any  .given  instance. 

From  the  foregoing  we  may,  therefore,  arrive  at  the  following  con- 
clusions: 


ANOMALIES   OF   AUDITION.  327 

I.  When  the  vibrating  tuning-fork,  placed  on  teeth  or  vertex  is' 
better  heard  through  the  tissues  on  one  side,  it  simply  indicates  that 
the  better  ear  excludes  wholly  or  in  part  such  (tissue)  transmission, 
but  it  does  not  prove  that  the  auditory  nerve  in  either  ear  is  affected. 

(Of  course,  if  the  nerve  of  audition  be  gravely  affected,  sound  will 
not  be  heard  by  any  method  of  conduction.) 

II.  If  the  conductive  mechanism  is  absent  or  greatly  damaged  in 
one  ear,  while  the  other  remains  normal,  aerial  transmission  will  be 
found  to  be  more  or  less  ineffectual  in  the  diseased  ear,  Avhile  the 
tuning-fork  allowed  to  vibrate  as  before  will,  therefore,  be  best  heard 
in  the  diseased  ear,  and  its  vibrations  will  be  almost  entirely  excluded 
from  the  healthy  ear. 

III.  In  deafness  from  labyrinthine  disease,  pure  and  simple,  the 
middle  ear  being  normal,  the  tuning-fork  will  be  best  heard,  if  heard 
in  any  degree,  by  aerial  conduction,  because  bone  conduction  would 
be  excluded. 

(In  those  extreme  cases  where  destructive  disease  of  the  nerve  has 
taken  place,  impulses  of  sound  may  be  appreciated  irrespective  of 
either  the  transmitting  or  labyrinthine  structures;  thus  the  deaf- 
mute  is  conscious  of  the  sound  of  thunder,  artillery,  drums,  stamp- 
ing with  the  foot  upon  a  floor,  and  the  like.) 

NOISES  IN  THE  EAR. 

Tinnitus  Aurium.  Persons  frequently  seek  relief  for  the  distress 
arising  from  these  sensations  solely,  though  considerable  deafness 
may  have  long  existed  without  inconvenience. 

Noises  in  the  ears  and  head  are  nearly  always  present  in  some  de- 
gree in  both  acute  and  chronic  aural  disease,  and  ka  nowledge  of  their 
significance  is  necessary  in  arriving  at  a  correct  diagnosis.  It  is  well 
to  remember  that  the  imagination  and  descriptive  power  of  each  pa- 
tient varies  in  regard  to  the  character  of  the  noise  experienced.  Neu- 
ropathic and  mentally  unsound  persons  often  give  very  absurd  and 
whimsical  accounts  of  their  sensations  in  this  respect.  Though  these 
noises  are  altogether  subjective,  patients  are  apt  to  fancy  that  others 
can  hear  them. 

The  most  common  description  of  noises  in  the  ear  is  that  of  tink- 
ling or  tingling,  "  a  tremulous  jarring  in  the  ears  like  ringing  metal, 
when  struck,"  as  the  continuous  vibrations  of  a  bell. 

They  frequently  remind  the  patient,  however,  of  some  familiar 
sound;  thus  the  domestic  fancies  that  they  resemble  the  sound  of 
frying  food,  boiling  water,  and  the  like;  the  rustic  compares  them 


328  ANOMALIES    OF   AUDITION. 

to  the  agitation  of  leaves  in  the  forest  by  the  wind,  or  the  singing  of 
insects,  etc.  Persons  accustomed  to  the  roar  of  the  surf,  or  to  water 
falls,  or  machinery,  or  music,  have  these  sounds  brought  to  mind. 
Sometimes  a  monotonous  ringing  or  singing  in  the  ear  is  experienced 
continuously.  In  chronic  catarrh  of  the  middle  ear,  these  phenomena 
are  very  constant;  the  more  sensitive  or  imaginative  being  greatly 
distressed  by  them,  whilst  insensitive  and  unimaginative  persons  often 
scarcely  note  their  existence. 

Noise  in  the  ear,  seldom  absent  in  chronic  middle  ear  affections, 
is  subject  to  exacerbations  from  mental  excitement,  especially  when 
this  causes  increased  cardiac  action;  it  may  then  be  so  excessive  as  to 
greatly  increase  deafness  by  interference.  The  despondency  and 
alarm  experienced  by  patients  from  this  cause  will  be  more  fully  con- 
sidered further  on. 

Noise  is  scarcely  ever  absent  in  acute  aural  affections  of  any  region 
of  the  ear,  and  not  infrequently  is  so  marked  as  to  be  referred  to  as 
pain.  The  writer  recalls,  among  the  descriptions  of  their  sufferings 
given  by  patients,  the  significant  statement  of  a  woman,  that  she 
had  a  "roaring  pain  "  in  her  ear,  and  of  another,  that  she  experienced 
a  " noisy  dizziness  in  the  head."  When  pain  and  vertigo  are  asso- 
ciated together  in  aural  troubles,  as  was  evident  in  the  above 
instances,  the  distress  to  the  patient  is  sometimes  most  alarming. 

The  causes  of  noises  in  the  ear  are  by  no  means  always  the  same, 
though  similar  phenomena  are  doubtlessly  due  to  similar  causative 
influences.  Perception  of  sound  implies  the  previous  existence  of 
sound  vibrations,  and  since  the  perceptive  tract  of  the  brain  itself  is, 
probably,  not  liable  to  thus  propagate  sound  in  its  own  tissues,  we 
must  look  to  the  inuer  and  middle  ear  for  their  origin,  and  especially 
to  anomalies  in  the  transmitting  mechanism  of  the  latter. 

The  physiological  function  (auditory)  of  the  portio  mollis  of  the 
seventh  pair  of  cranial  nerves  would  seem  to  consist  in  carrying 
impressions  whose  mode  of  motion  is  adapted  to  nerve  transmission. 
Touch  upon  any  surface  of  the  body  is  thus  transmitted  by  sensory 
nerves,  and,  whilst  the  auditory  nerve  is  more  highly  specialized  in 
respect  to  aerial  touch  upon  the  drum-head,  it  seems  to  be  susceptible 
"to  other  sensory  impressions  also  to  some  extent,  since  vertigo  or 
shock  may  ensue  from  syringing,  probing,  or  wounding  the  ear. 

There  seem  to  be  two  principal  sources  of  noise  in  the  ear, 
namely:  1.  From  disturbance  of  tension  of  the  transmitting  mech- 
anism of  the  ear,  and  2.  From  disturbance  of  tension  of  the  percep- 
tive mechanism  of  the  ear. 

I.  Noises  due  to   disturbances   of  the   drum  may  be  of  temporary 


ANOMALIES    OF    ADDITION.  329 

duration  only,  as  from  hyperaemia  due  to  flushing,  or  congestion,  the 
effects  of  head  cohls  in  which  the  drum  cavity  is  involved,  reflected 
dental  or  naso-pharyngeal  irritation,  etc.,  or  otitis  media  from  any 
cause.  Eecovery  from  these  is  often  speedy  and  without  leaving  any 
permanent  defect. 

Where  sensory  affections  of  the  drum  have  produced  hypertrophic, 
atrophic,  or  sclerotic  changes,  the  transmitting  mechanism  may  be- 
come relaxed  on  the  one  hand,  or  ankylosed,  especially  the  stapes,  on 
the  other  hand.  In  otorrhoea,  or  in  some  subjects  of  chronic  pul- 
monary or  renal  disease,  where  rapid  and  irreparable  breaking  down 
of  tympanal  tissue  takes  place,  excessive  disturbances  in  audition  are 
experienced,  and  other  sounds  than  buzzing  or  ringing  take  place, 
to  which  allusion  will  soon  be  made.  In  the  sudden  deafness  due  to 
syphilis'  noises  and  vertigo  are  specially  marked. 

When  changes  in  the  structure  of  the  drum  take  place  from  trophic 
or-  other  pathological  causes,  resulting  in  loss  of  tension  or  in  fixation 
of  the  o^sicula,  noises  are  more  or  less  permanent. 

Collections  of  fluids  or  other  products,  of  inflammation  in  the 
tympanum,  interfere  with  the  movements  of  the  transmitting  appara- 
tus, and  also  alter  the  resonance  of  the  drum  cavity;  the  significance 
of  these  will  be  duly  considered. 

Contractions  of  the  tensor  tympani  muscles  are  sometimes  the  cause 
of  noise  in  the  ears,  as  well  as  the  impaction  or  occasional  impinge- 
ment of  cerumen  or  foreign  bodies  on  the  drum-head. 

II.  The  disturbance  that  sometimes  occurs  in  comparatively  healthy 
ears  from  the  effects  of  alcoholic  stimulants,  quinine,  anesthetics, 
tea,  coffee,  tobacco  when  smoked,  mental  emotion,  strain  of  the  res- 
piratory and  abdominal  muscles  in  efforts  at  expulsion  of  the  contents 
of  those  cavities,  etc.,  whereby  nervous  tension  is  impaired,  seems  to 
give  rise  to  nervous  impulses  which  become  audible.  They  are  heard 
as  gentle  tingling  or  hissing  sounds  commonly  known  as  tinnitus 
aurium.  Such  phenomena  have  been  regarded  as  due  to  increased 
vascular  activity,  and,  indeed,  our  present  knowledge  of  nerve  action 
is  too  limited  to  satisfactorily  explain  the  modus  operandi  of  trans- 
mitted nerve  force  (or  whatever  it  may  be  called),  and  the  views  ad- 
vanced must,  of  course,  be  regarded  as  suggestive  only  until  verified 
by  further  observation. 

In  regard  to  the  anomalies  of  hearing  due  to  defects  in  the  trans- 
mitting mechanism,  it  may  be  said,  that  the  moment  aerial  sound 

'Vide  "The  Sudden  Deafness  of  Syphilis."  Samuel  Sexton:  American 
Journal  of  the  Med.  Sciences,  July,  1879. 


330  ANOMALIES    OF    AUDITION. 

transmission  suffers  impairment,  hitherto  unheard  undulatory  move- 
ments arising  from  the  circulation  of  blood  in  the  neighborhood  of 
the  ear,  and  other  sounds,  are  taken  cognizance  of  through  inter- 
vening tissues,  specially  the  osseous.  The  impracticability  of  tissue 
conduction  ordinarily  is  due  to  the  fact  that  in  normal  tension  of  the 
conductive  mechanism  of  the  middle  ear  other  sounds  than  aerial  are 
practically  excluded.  But  besides  the  noises  arising  from  vibrations 
occasioned  by  the  movement  of  blood  in  the  arterioles  in  the  imme- 
diate neighborhood  of  the  ear,  other  and  louder  sounds  are  also  some- 
times heard,  arising  from  cardiac  and  respiratory  movements,  vocali- 
zation, the  flow  of  blood  through  the  carotid  canal,  the  lateral 
sinuses,  etc.,  and  the  acts  of  deglutition.  The  sounds  of  the  heart 
seem  to  follow  the  column  of  blood  up  to  the  ear,  giving  rise  to  throb- 
bing or  pulsating  sounds.  In  acute  middle  ear  inflammation  the 
sensation  is  sometimes  described  as  that  of  the  violent  action  of  an 
engine's  piston  or  of  pumping  machinery.  The  concussions  of  the 
carotid  are  probably  more  severe  when  fluid  is  present  in  the  drum, 
their  frequency  being  synchronous  with  the  beating  of  the  heart. 

Another  group  of  sounds  proceed  from  the  friction  of  the  articular 
surfaces  of  the  ossicles  themselves,  either  during  excursions  of  the 
membrana  tympani,  or  when  the  patient  moves  the  head  suddenly, 
or  sloops;  they,  of  course,  are  not  continuous.  These  sounds  are  de- 
scribed by  patients  as  ''ticking,"  "  rubbing,"  ''grating,"  etc.,  or  like 
"  something  loose  in  the  ear."  In  some  instances  the  noises  resemble 
the  sound  produced  by  jingling  delicate  pieces  of  metal  together, 
in  others,  the  tapping  of  wooden  substances;  the  pitch  varying  in 
almost  every  case  and  in  the  different  stages  of  the  affection. 

The  drum-head  also  contributes  peculiar  noises  of  its  own  when 
its  tension  is  lost  and  the  humidity  of  the  drum  is  either  greater  or 
less  than  normal.  Thus,  when  agitated  by  sound  vibrations  or  acts 
of  swallowing,  respiration,  or  eructations,  the  relaxed  and  dry  mem- 
brane gives  forth  a  rattling  noise  like  the  crumpling  of  parchment 
or  paper,  and  when  tenacious  mucus,  and  the  like,  is  present  the  ear 
seems  to  "open  and  close"  under  the  conditions  just  described,  with 
a  feeling  of  separation  between  two  sticky  surfaces. 

Whilst  the  phenomena  of  noises  in  the  ear  may  occur  in  the  course 
of  most  aural  affections,  in  advanced  life  they  are  particularly  dis- 
tressing, since  senile  changes  in  the  drum  are  liable  to  gradually 
render  the  transmitting  mechanism  defective  even  where  chronic  in- 
flammation has  not  been  marked.  The  distress  of  the  menopause  is 
greatly  increased  by  the  co-existence  of  aural  disease  attended  with 
auditory  acoustic  anomalies,  as  is  shown  by  the  following  case: 


ANOMALIES    OF    AUDITION.  331 

The  patient  was  a  lady.  51  years  of  age,  who  consulted  the  writer 
in  1877.  There  was  a  history  of  deafness  and  tinnitus  of  several 
years'  duration,  after  which  attacks  of  the  character  under  consid- 
eration began  to  come  on,  with  flushing  about  the  face  and  head,  with 
great  nervousness  and  vertigo.  The  tinnitus  experienced  was  most 
painful,  she  herself  designated  it  as  "frightful,  like  the  rattle  and 
crash  of  a  train  of  freight  cars  *'  at  one  time,  whilst  at  another  it 
seemed  "like  the  rumble  caused  in  a  room  overhead  by  rolling  bar- 
rels over  the  floor.'"  Sometimes  she  heard  "the  rushing  of  water  or 
the  intense  roar  of  steam  escaping  from  the  steamer's  funnel,"  and 
other  disagreeable  sounds.  Finally,  after  becoming  exhausted  by  a 
severe  attack,  an  interval  of  comparative  repose  ensued,  during  which 
she  fancied  that  she  heard  the  singing  of  a  church  choir  in  the  left 
(worse)  ear.  This  occurred  in  the  retirement  of  her  own  room  where 
quietness  prevailed,  and  has  since  frequently  recurred.  When  upon 
the  street,  in  a  railway  train,  or  where  there  is  much  noise,  she  not 
only  hears  much  better,  but  is  quite  free  from  the  distressing  acoustic 
phenomena  above  described. 


AUTOPHONIA. 

8yn.  Pseudacousma  or  False  Hearing.  The  tension  of  the  trans- 
mitting mechanism  of  the  middle  ear,  or  the  resonance  of  the  drum 
become  so  changed  in  certain  aural  troubles  that  the  patient  fails  to 
hear  his  own  voice  in  the  usual  manner;  it  does  not  appear  to  issue 
forth  from  his  mouth,  and  then  come  around  and  strike  upon  his  ear- 
drums. It  seems  to  fail  of  utterance  in  the  usual  manner,  but  passes 
directly  up  to  the  speaker's  ear  from  within  the  head.  Speech  thus 
gains  access  to  the  nerve  of  hearing  by  traversing  the  tissues  between 
the  vocal  organs  and  ears  in  a  direct  line,  or  along  the  aerial  tract  of 
the  Eustachian  tube  when  open.  And,  in  fact,  the  sounds  of  the 
patient's  own  voice  also  pass  into  the  ear  to  a  greater  or  less  extent 
in  the  usual  manner,  though  seeming  to  reach  it  from  within  alto- 
gether, since  the  voice  of  others  may  be  quite  well  heard  in  the 
a,ffected  ear.  Sometimes  both  ears  are  affected  in  this  manner,  but  if 
the  disease  is  confined  to  one  of  them,  he  then  receives  normal  sound 
impressions  in  the  usual  way  in  one  ear,  whilst  the  same  impressions 
•are  perverted  by  the  other  ear,  and  are  heard  a,s  false  both  as  regards 
pitch  and  timbre.  In  a  certain  number  of  cases  the  resonance  of  the 
■drum  cavity,  with  or  without  unusual  patulency  of  the  Eustachian 
tube,  is  such  that  a  distinct  "echo  "  occurs  after  each  word  spoken. 

Autophonia  occurs  during  the  progress  of  a  large  number  of 
middle  ear  affections ;  also  in  diffuse  and  circumscribed  inflamma- 
tion of  the  external  auditory  canal,  and  from  the  presence  of 
ceruminal  collections  or  foreign  bodies  therein.     The  anomalies  of 


332  ANOMALIES    OF    AUDITION. 

hearing  due  to  intra-tympanal  air-renewal  include  this  phenomenon^ 
and  the  impact  of  sound  or  of  water  syringed  into  the  ear  may 
cause  it. 

In  both  acute  and  chronic  affections  of  the  middle  ear,  though 
most  frequently  in  the  latter,  the  articular  surfaces  of  the  ossicula. 
are  liable  to  be  disturbed,  especially  the  malleo-incudal  joint ;  and 
one  result  of  this  is  loss  of  tension.  Tension  is  also  disturbed  where 
manometric  restoration  of  the  drum-head  exists. 

In  respect  to  the  former,  it  is  well  known  that  the  peculiar  con- 
struction of  the  malleo-incudal  joint  permits  of  disarticulation  in 
such  a  way  that  the  transmitting  mechanism  fails  to  respond  nor- 
mally to  sound-waves  arriving  through  the  meatus  externus,  while 
those  propagated  by  phonation,  respiration,  circulation,  etc.,  are  now 
effective  upon  the  base  of  the  stapes,  and  probahly  also  upon  the 
membrana  tympani  secundaria.  In  both  anomalies  effective  oscilla- 
tion of  the  drum-head  requires  increased  intensity  of  aerial  impact, 
since  it  must  be  forced  inward  far  enough  to  re-establish  tension, 
through  coaptation  of  the  articular  surfaces  in  one  instance,  or  by 
putting  the  relaxed  membrane  on  the  stretch  in  the  other. 

When,  sound  passes  from  the  vocal  organs  to  the  ear,  via  the 
Eustachian  tube  coincidentally  with  its  passage  through  solids,  there 
is  much  confusion  from  interference,  and  when  the  voice  of  others 
is  heard  at  the  same  time,  the  discomfort  is  further  increased. 

The  closure  of  the  Eustachian  tube  in  acute  inflammation  of  the 
drum,  with  consequent  retraction  of  the  drum-head,  niay  also  give  rise 
to  autophonia. 

It  would  seem  that  in  certain  derangements  of  the  euphonious  ear 
by  disease,  the  back  door  of  the  organ  is  thrown  wide  open  to  the  wild 
uproar  of  tuneless  noises,  and  that  beside  the  bewildering  effect  of 
the  autophonous  voice,  cognizance  is  taken  also  of  the  sounds 
propagated  by  the  busy  circulatory  movements  occurring  always, 
though  unheard  in  the  healthy  state,  in  the  blood-vessels  which 
course  near  the  ear.  The  din  often  experienced  seems  to  be  al- 
together out  of  proportion  to  the  origin  of  the  sounds,  and,  especially 
in  nervous  subjects,  the  vibrations  caused  by  the  larger  vessels,  and 
by  the  autophonous  voice,  often  seem  to  possess  the  pitch  of  thunder 
or  artillery  detonations — the  head  and  ear  being  fairly  rent  and  split 
with  the  resounding  clangor.  The  writer  has  even  known  persons 
to  declare  that  the  sensations  experienced  were  to  be  compared  to  the 
rushing  and  rattling  movements  of  a  railway  train  traversing  the 
head. 

The  apalling  effect  of  these  deafening  and  piercing  reverberations 


ANOMALIES    OF    AUDITION.  333 

can  be  better  understood  when  it  is  considered  that  the  head  in  auto- 
phonia  very  often  seems  like  an  echoing  cavern  in  which  these  violent 
sounds,  consisting  in  part  of  slamming,  cracking,  snapping,  knock- 
ing, clashing,  rumbling,  humming  and  hissing  noises,  suddenly 
manifest  themselves.  That  the  impact  of  these  autophonous  vibra- 
tions often  gives  rise  to  cerebral  disturbances,  though  not  always  to 
the  extent  of  producing  unconsciousness,  and  leaves  the  patient  in  a 
prostrate  condition,  can  be  readily  understood. 

Next  in  importance  to  the  changes  in  the  ossicula  as  a  causative 
abnormity  is  the  movable  drum-head  which,  indeed,  is  the  essential 
agency  in  causing  the  interruptions  that  occur  in  pseudacousma ; 
or  so  long  as  a  certain  tension  in  the  ossicular  chain  remains,  the 
drum-head  may  be  greatly  relaxed,  suffer  much  loss  of  substance  by 
perforative  inflammation,  or  become  thickened  and  loaded  with 
opacities,  without  causing  false  hearing.  Some  authorities  trace  the 
origin  of  many  of  these  phenomena  to  affections  of  the  inner  ear,  but 
the  writer  does  not  believe  that  a  decisive  conclusion,  in  which  all 
shall  agree,  will  be  reached  until  more  time  and  attention  shall  have 
been  devoted  to  the  study  of  the  physiology  and  pathology  of  this 
subject. 

Absolute  certainty  in  diagnosis  is  not  possible  until  our  knowledge 
of  the  physiological  functions  of  the  terminal  filaments  of  the 
auditory  nerve  has  a  more  substantial  foundation  than  theory  alone. 
Otologists  have  given  no  little  attention  to  the  subject,  however, 
during  the  past  fifteen  or  twenty  years. 

Patients  who  experience  autophony  are  aware  that  the  pitch  of  the 
voice  has  undergone  a  change ;  in  certain  cases  it  seems  lower  than 
natural,  and  sometimes  it  is  described  as  hoarse  ;  such  patients,  when 
singing  or  speaking,  raise  the  voice  above  the  natural  pitch.  On 
the  other  hand,  the  voice  sounds  unusually  loud  to  some  individuals, 
and,  in  order  to  avoid  disturbing  others,  they  speak  in  low,  or 
even  whispering  tones.  When  autophony  is  intermittent,  the 
patient  will  alternately  raise  and  lower  the  voice  during  conversa- 
tion. 

The  following  case  is  of  interest  here: 

The  patient  was  a  commercial  traveller,  34  years  of  age.  He  was 
first  seen  by  the  writer  in  April,  1879,  at  which  time  he  believed  him- 
'self  to  have  some  throat  trouble.  A  careful  examination  of  the  vocal 
organs  had  been  made,  but  all  assurances  of  their  healthf ulness  failed 
to  entirely  convince  him  that  the  difficulty  was  elsewhere.  An 
examination  showed  that  there  was  chronic  catarrhal  inflammation 
•of  both  ears,  evidently  of  long  standing.     The  voice,  he  stated,  had 


334  ANOMALIES    OF    AUDITION. 

been  autophonous  for  three  years,  and  it  sounded  so  disagreeably  that 
he  was  unable  to  sustain  vocal  efforts  long  at  a  time.  In  consequence 
of  this  disability  he  lost  his  situation,  and,  for  a  short  time  before 
consulting  the  author,  his  precarious  livelihood  depended  on  his  ex- 
ertions as  a  canvasser.  Whenever  the  autophony  came  on — it  was  in- 
termittent— all  business  had  to  be  put  aside  for  a  time,  and  some 
attacks  lasted  for  hours,  when  the  mental  depression  was  great.  These 
attacks  came  on  quite  suddenly,  were  characterized  by  most  distress- 
ing roaring  in  the  ears,  which  was  increased  by  every  attempt  to  use 
the  voice.  The  mental  condition  seemed  to  favor  palpitation  of  the 
heart,  and,  altogether,  the  attacks  left  him  exhausted  for  a  time  and 
incapacitated  for  work.  The  tinnitus  aurium  and  autophony  were  the 
cause  of  great  deafness,  but,  when  absent,  the  hearing  was  good.  This 
patient  asserted  that  he  had  frequently  thought  that  suicide  would  be 
preferable  to  the  distress  he  had  to  endure.  The  writer's  first  ell'ort 
in  this  case  was  to  convince  the  patient  that  the  anomalies  experienced 
in  no  way  prognosticated  danger  to  life,  and  an  absence  of  dread  has 
been  followed  by  almost  entire  relief  as  regards  the  severe  paroxysms 
described. 

These  phenomena  cannot  be  experienced  by  any  persons  without 
distress,  for  even  a  simple  cold  in  the  head  may  give  rise  to  false 
hearing,  not  from  physical  disability  as  regards  the  throat,  but  from 
the  autophonous  voice  that  so  accompanies  the  *' stuCQness^' in  the 
ears  then  felt.  This  condition  should  not  be  confounded  with  the 
simple  nasal  tone  acquired  by  reason  of  a  stoppage  of  the  nasal 
passages  from  any  cause,  for  in  this  state  the  patient's  voice  sounds 
alike,  both  to  himself  and  others. 

False  hearing  and  autophony  may  be  experienced  at  any  age. 
They  usually  announce  themselves  suddenly  in  the  course  of  acute 
aural  affections,  as  has  already  been  stated,  and  disappear  as  quickly. 
In  chronic  cases,  however,  their  development  is  more  gradual,  and 
they  are  then  more  persistent. 

The  transmission  of  sound,  under  certain  circumstances,  through 
the  tissues  of  the  body  to  an  ear  affected  by  disease,  is  of  frequent 
occurrence.  Patients  not  infrequently  complain  of  the  unpleasant 
sensation  thus  experienced  by  hearing  their  own  footsteps  on  the 
pavement,  or  the  heavy  rumbling  sounds  of  the  street. 

THE     EFFECTS     OF    FALSE    HEARING     (AUTOPHONIA) 

ON  SINGERS,   ACTORS,   LECTURERS,   AND 

MUSICIANS. 

The  consequences  of  false  hearing  are  very  serious  to  those  who 
earn  a  livelihood  by  the  use  of  the  voice.  It  often  happens,  however, 
that,  when  incapacitated  for  their  pursuits,  attention  is  not  directed 


ANOMALIES    OF    AUDITION.  335 

to  the  real  source  of  trouble  in  the  ear,  but  advice  is  sought  for  some 
fancied  affection  of  the  throat,  which  is  supposed,  to  modify  the  voice. 

The  consequences  of  autophonia  in  decided  impairment  of  the 
ear  structures  are  most  appalling  to  musicians,  since  the  mind,  can 
•  receive  harmonious  impressions  no  longer;  singing  or  instrumental 
performances  are  not  possible,  but  the  mere  perception  of  music  gives 
rise  to  disagreeable  emotions.  When  the  subject  of  false  hearing  per- 
forms on  certain  musical  instruments,  especially  upon  the  violin  or 
the  cornet — instruments  held  in  contact  with  the  face  or  lips  when 
played  upon — he  finds  that  sonorous  vibrations  appear  to  fail  to  issue 
forth  from  the  instrument;  that,  like  autophonous  voice,  they  are 
only  recognized  by  him  as  resounding  within  the  head. 

The  following  cases  from  the  author's  records  illustrate  what  has 
been  above  stated. 

The  vocalists  are,  for  convenience,  arranged  in  one  group,  the  per- 
formers on  musical  instruments  in  another. 

CLASS   I. — VOCALISTS. 

Case  1. — A  singer,  52  years  of  age,  suffering  from  an  acute  puru- 
lent inflammation  of  the  left  middle  ear,  which  had  been  greatly 
aggravated  by  the  ill-advised  use  of  an  irritating  lotion.  There  was 
deafness  to  ordinary  sounds,  and  in  speaking  he  experienced  auto- 
phony;  when  he  attempted  to  sing  in  the  church  choir  to  which  he 
belonged,  he  was  unable  to  strike  the  correct  pitch,  his  voice  sounding 
unnatural  to  him;  when  he  sang,  his  notes  were  a  "  confused  jumble," 
as  he  himself  expressed  it.  This  case  proved  to  be  a  very  grave  one, 
and  the  permanent  injury  to  the  conductive  mechanism  prevented  an 
entire  cure  as  regards  the  autophony.  After  his  entire  recovery  from 
all  inflammation,  which  took  place  in  about  a  month,  the  autophony 
yet  remained  in  some  degree;  he  could,  however,  remove  the  symp- 
toms by  pulling  the  tragus  firmly  outward  and  downward. 

Case  2. — Patient,  a  lady,  34  years  of  age,  came  to  the  writer's 
oflBce  in  September,  1880,  with  chronic  catarrhal  inflammation  of 
both  middle  ears.  The  disease  was  of  several  years'  standing,  and 
since  it  was  first  noticed  until  the  present  time  there  has  been  a 
gradual  increase  in  the  deafness,  and  she  can  now  only  hear  loud 
conversation.  For  two  years  past  she  has  been  unable  to  sing  without 
hearing  the  sound  of  her  voice  most  unpleasantly  in  her  ears;  how- 
ever great  her  efforts,  the  notes  appear  to  die  away  without  utterance. 
Her  voice  is  a  very  good  one,  but  she  sings  without  any  confidence  in 
her  own  power.  She  hears  conversation  best  when  in  a  rumbling 
conveyance,  or  on  a  noisy  street. 

Case  3. — A  gentleman,  46  years  of  age,  while  suffering  from  an 
itching  of  the   external   auditory  meatus,  was  advised  to  drop  into 


336  ANOMALIES    OF    ADDITION. 

the  ear  a  weak  solution  of  carbolic  acid.  By  mistake  he  prepared 
a  mixture  of  equal  parts  of  concentrated  carbolic  acid  and  glycerin, 
a  drop  or  two  of  which  was  put  into  the  left  ear.  He  instantly 
experienced  pains  of  a  most  excruciating  character,  and  although 
water  was  at  once  instilled  into  the  ear  to  dilute  the  mixture,  per- 
foration of  the  drum-head  ensued,  and  acute  purulent  inflammation 
of  the  middle  ear  was  established.  The  accident  that  gave  rise  to 
these  unpleasant  symptoms  occurred  in  February,  1878,  and  owing  to 
the  patient's  run-down  condition,  it  was  nearly  twelve  months  before 
recovery  took  place.  Throughout  the  attack  the  voice  was  auto- 
phonous,  as  regards  the  left  ear — a  symptom  that  annoyed  the  patient 
very  much,  for  he  had  a  musical  voice,  and,  before  the  attack,  de- 
rived much  pleasure  in  singing  duets  with  his  wife  at  social  gather- 
ings; owing  to  the  autophony,  however,  his  voice  seemed  flat — to 
himself  it  was  about  half  a  note  low.  He  was  very  sure,  at  first,  that 
the  throat  was  in  some  way  involved  in  the  difficulty;  an  explanation 
of  the  phenomena,  however,  corrected  his  mistake.  When  the  ear 
was  cured,  the  ability  to  use  the  voice  in  singing  returned. 

Case  4. — Male  patient,  43  years  of  age,  leader  of  a  church  choir, 
consulted  the  author  in  September,  1878,  for  a  subacute  catarrhal  in- 
flammation of  both  middle  ears,  engrafted  upon  a  chronic  catarrhal 
inflammation  of  long  duration.  The  subacute  attack  was  attributed 
to  a  severe  cold.  There  was  autophonous  voice  in  both  ears,  but  in 
the  right  one  it  was  occasionally  absent.  When  speaking  or  singing 
the  voice  seemed  to  strike  the  ears,  especially  the  left  one,  most  un- 
pleasantly, the  words  failing,  as  he  fancied,  to  find  utterance  from 
the  mouth.  The  autophony  sometimes  alternated  from  one  ear  to 
the  other,  and  it  was  more  or  less  intermittent  in  both  of  them.  His 
attempts  to  sing  with  the  choir  were  the  cause  of  both  astonishment 
and  amusement  to  the  auditors,  and  as  for  himself,  he  was  utterly 
discomfited  by  the  misfortune,  and  sorrowfully  acknowledged  that 
his  "  voice  was  out  of  tune."  Although  unable  to  sing  with  others, 
when  examined  he  heard  correctly  the  notes  of  a  hand-organ  in  the 
street,  which  was  at  that  moment  playing  a  selection  from  "  H 
Trovatore."  Entire  recovery  did  not  take  place  in  the  three  months 
that  he  remained  under  observation. 


CLASS   II. — PERFORMERS   ON   MUSICAL  INSTRUMENTS. 

Case  5.— A  teacher  of  music,  67  years  old,  seen  in  March,  1879, 
then  suffering  from  an  acute  purulent  inflammation  of  the  left  mid- 
dle ear.  The  attack  was  ushered  in  with  very  severe  pains  and  tin- 
nitus, and  the  patient  was  soon  dismayed  to  find  that  when  he  at- 
tempted to  play  upon  the  violin  its  notes  were,  to  himself,  anything 
but  musical;  in  fact,  the  favorite  instrument  that  had  never  failed  to 
respond  in  rhythmical  sympathy  to  his  cultivated  touch,  now  sent 
forth  noisy  discordant  sounds  only.  He  also  discovered,  much  to  his 
astonishment,  that  his  voice  was  autophonous.  The  false  hearing, 
both  for  the  voice  and  for  the  violin,  was  confined  to  the  left  ear,  and 
inquiries  elicited  the  fact  that  the  strange  conduct  of  his  violin  only 


AUTOPHONIA.  337 

manifested  itself  when  held  against  the  left  cheek  while  played  upon, 
for  when  it  was  held  away  from  the  face  its  tones  were  heard  in  the 
usual  way.  Normal  hearing  returned  on  his  recovery  from  the  aural 
disease,  which  was  in  about  three  months  from  the  beginning  of  the 
attack. 

Case  6. — This  patient  performs  on  a  cornet  in  a  small  orchestra; 
he  is  35  years  old.  He  came  to  the  writer  in  January,  1879,  while 
suffering  with  an  acute  purulent  inflammation  of  the  left  middle 
ear;  in  this  ear  he  was  deaf  to  ordinary  voice.  When  he  plays  on  the 
cornet  he  fancies  that  no  sound  issues  forth  from  the  instrument,  but 
that  from  his  lips  the  vibrations  go  back  to  the  left  ear,  from  which 
they  resound  again  most  unpleasantly.  When  attempting  to  play 
upon  the  cornet  with  the  orchestra,  it  seems  to  himself  to  be  pitched 
a  quarter  of  a  note  higher  than  the  other  instruments,  and  when  h& 
lowers  the  pitch  to  that  of  the  orchestra,  he  is  told  that  he  plays  too. 
low.  After  several  futile  attempts  to  play  in  tune,  he  was  obliged  to 
throw  up  his  engagement.  A  violin  played  upon,  while  resting 
against  his  left  cheek,  sounds  more  loudly  than  if  heard  in  the  natural 
manner.  The  effect  of  orchestral  music  on  the  affected  ear  was  pe- 
culiar— it  seemed  to  be  "  damped.'*  The  cornet's  tones,  for  example, 
sounded  like  that  instrument  when  the  "  mute  "  is  used.  The  music, 
however,  was  distinguished,  unless  low  tones,  which  were  first  im- 
parted to  the  floor  before  reaching  his  ear  through  the  body,  had  the 
effect  to  confuse  his  perception  in  some  degree.  By  placing  his  hands 
on  a  piano,  while  the  cords  were  in  a  state  of  vibration,  the  sound, 
was  carried  to  the  affected  ear  through  the  tissues  of  the  body.  Thig 
patient's  voice  was  autophonous.  His  recovery  from  the  severe  aural 
affection  was  slow;  a  cure,  however,  was  effected  in  three  or  four 
months,  and  it  was  then  found  that  he  had  not  been  permanently 
incapacitated,  inasmuch  as  he  resumed  his  former  place  in  the 
orchestra. 

Case  7. — Patient  is  likewise  a  cornet  player.  His  age  is  53  years. 
The  author  first  saw  him  in  September,  1880,  three  weeks  after 
he  had  contracted  a  severe  cold  from  exposure  going  home  one 
stormy  night  from  a  performance.  A  few  days  after  the  exposure 
there  was  deafness  in  the  left  ear,  and  he  could  not  hear  conversation 
spoken  in  a  low  tone.  Examination  showed  an  acute  catarrhal  in- 
flammation of  the  middle  ear.  It  was  found  that  he  was  deaf  to  the 
notes  of  the  highest  organ-pipe.  When  he  plays  upon  the  cornet,  the 
whole  volume  of  sound  seems  to  himself  to  pass  backward  and  escape 
out  of  his  head  through  the  left  ear.     He  has  autophonous  voice. 

The  attack  in  this  instance  was  a  mild  one,  and  the  patient  resumed 
his  place  in  the  orchestra  in  about  a  week  after  he  first  came  under 
observation. 

He  could  play  upon  the  violin,  and  from  an  experiment  made 
during  the  aural  attack  it  was  found  that  this  instrument  was  heard 
false,  the  phenomena  experienced  being  the  same  as  were  reported 
by  the  previous  patient  under  very  similar  conditions. 

Case  8. — The  patient,  a  teacher  of  music,  aged  41  years,  was  sent 


338  AUTOPHONIA. 

by  a  medical  friend  in  October,  1879.  His  deafness  was  very  great; 
he  hears  words  only  when  shouted  directly  into  his  ears.  For  the 
past  eleven  years  he  has  suffered  greatly  from  both  autophony  and 
tinnitus  aurium.  The  cause  of  these  most  unpleasant  symptoms  is 
chronic  catarrhal  inflammation  of  both  the  middle  ears.  He  has  be- 
come exceedingly  nervous  and  irascible,  and  his  conduct  makes  his 
family  as  wretched  as  himself.  Thoughts  of  putting  an  end  to  his 
life  are  constantly  in  his  mind.  He  states  that  since  his  sufferings 
began  he  has  been  under  the  treatment  of  nearly  every  prominent 
aurist  in  this  country  and  in  Germany,  besides  many  general  practi- 
tioners, but  without  benefit  from  any;  indeed,  it  is  to  be  feared  that 
his  sufferings  have  been  increased  by  the  frequent  inflations  to  which 
the  drums  have  been  subjected  by  the  Politzer  method.  Before  he 
had  any  serious  disease  of  the  ears,  he  played  upon  several  musical 
instruments,  but  their  sounds  to  him  are  now  tormenting.  His  wife 
states  that  he  is  most  of  the  time  "  wild  with  nervousness, '*  that 
the  noises  in  the  head,  when  the  voice  is  most  autophonous,  convince 
him  that  he  must  be  possessed  of  some  serious  ailment.  Frequently 
he  refers  to  his  throat  as  the  seat  of  some  disease.  For  several  years 
past  he  has  devoted  whatever  strength  and  means  remain  subject  to 
his  control,  to  travelling  about  in  search  of  relief.  This  patient  was 
benefited  by  the  use  of  cotton-wool  pellets,  adjusted  to  the  relaxed 
conductive  mechanism,  but  he  was  unable  to  keep  them  in  place  very 
long  without  causing  irritation  of  the  drum-head. 

Case  9. — This  girl  is  now  receiving  musical  instruction  on  the 
piano.  She  is  13  years  old,  and  has  a  talent  for  music.  She  was 
brought  to  the  writer  in  November,  1878,  while  suffering  with  acute 
catarrhal  inflammation  of  both  middle  ears,  caused  in  part  by  re- 
flected dental  irritation.  The  right  ear  was  most  affected,  but  the 
voice  was  autophonous  in  both.  With  the  autophonous  voice  in  the 
right  ear,  she  describes  the  sound  of  the  voice  as  remaining  there  a 
perceptible  period  of  time,  and  having  a  timbre  resembling  a  vibrat- 
ing piano  cord.  The  piano,  heard  at  a  distance,  sounds  damped,  but 
is  not  unmusical.  All  of  her  efforts  to  perform  on  the  instrument 
are  unsatisfactory,  for  the  sounds  reaching  the  ear  by  tissue-conduc- 
tion— through  the  body — are  heard  false,  and  create  an  unpleasant 
and  discordant  jangle.  A  good  recovery  was  made  in  about  two 
months,  when  she  resumed  her  musical  instruction.  The  hearing, 
which  of  course  had  been  imperfect,  was  entirely  restored. 

Case  10. — The  patient  is  an  organ-tuner,  aged  23  years.  His  hear- 
ing was  always  good  until  three  weeks  before  coming  under  observa- 
tion, in  September,  1879,  He  now  had  an  acute  purulent  inflamma- 
tion of  the  right  middle  ear.  In  this  ear  he  cannot  hear  ordinary- 
conversation.  In  the  other  ear  the  hearing  is  good.  There  is  auto- 
phony and  tinnitus  in  the  affected  ear.  He  is  unable  to  tune  an 
organ,  for  when  he  blows  the  tuning-pipe,  its  sounds  seem  to  be  within 
the  head;  and  furthermore,  the  beats  above  upper  F  are  indistin- 
guishable, unless  the  ear  is  close  to  the  pipe.  Normal  hearing  was 
restored  aiter  five  weeks'  treatment. 


AUTOPHONIA.  339 

It  will  thus  be  seen  that  in  false  hearing  the  sounds  of  the  voice  or 
the  cornet  are  transmitted  in  a  more  or  less  direct  course  through 
the  intervening  tissues  from  the  mouth  to  the  ear,  to  be  heard,  so  to 
speak,  from  within  the  head.  Undulations  of  sound  in  speaking, 
singing,  or  playing  upon  the  cornet  are,  of  course,  always  trans- 
mitted to  the  ears  through  the  intervening  tissues,  as  well  as  by  the 
air,  but  in  the  normal  state  of  the  transmitting  mechanism  the  former 
are  simultaneous  or  excluded;  otherwise,  there  would  be  confusion 
from  interference.  Even  if  these  media  transmitted  sound  from  the 
mouth  to  the  ears  with  equal  velocity,  confusion  would  still  ensue, 
for  the  ear  would  be  unable  to  harmonize  the  undulations  received  in 
both  a  normal  and  abnormal  manner  at  the  same  time — the  one  through 
the  air,  the  other  through  the  tissues.  A  patient  who  experiences 
autophony  finds  it  a  difficult  matter  to  locate  the  precise  source  of  his 
own  voice,  as  it  approaches  the  ear  from  an  unfamiliar  source;  this 
experience,  moreover,  seems  to  vary  in  different  patients,  some  locating 
it  in  the  ear  itself,  others  in  various  regions  of  the  head.  A  lady,  for 
example,  who  suffered  with  autophony,  informed  the  writer  that  her 
voice  seemed  to  go  out  of  the  back  of  her  head,  and  she  fancied  it  was 
heard  by  those  standing  behind  her  only.  To  some  the  vocal  intona- 
tion is  so  unfamiliar  that  it  is  difficult  for  them  to  believe  that  the 
voice  is  not  spoken  by  another,  and  that  the  speaker  is  at  a  distance  or 
in  a  different  apartment.  In  certain  instances  the  patients  describe  the 
voice  as  remaining  in  the  ear  a  perceptible  period  of  time  or  as  echo- 
ing in  the  head;  these  are  most  confusing  experiences,  inasmuch  as 
they  give  rise  to  the  sensation  of  the  head  being  ''empty  "  or  "hol- 
low." Musical  people,  when  experiencing  this  feature  of  pseuda- 
cousma,  either  in  singing  or  playing  upon  certain  instruments,  like- 
wise find  the  tones  produced  lingering  in  the  ear,  and  seeming  to 
have  a  different  pitch  than  at  their  inception. 

A  very  slight  cause,  as  a  cold  in  the  head,  may  so  disarrange  the  con- 
ductive mechanism  that  a  singer's  voice  becomes  false  to  an  incapaci- 
tating degree,  and  while  the  pseudacousma  exists  he  cannot  pitch  his 
voice  to  the  same  tone  with  other  singers  or  with  an  orchestra,  be- 
cause he  hears  his  own  voice  in  a  false  tone  as  compared  to  the  accom- 
panying tones  which  he  hears  with  greater  or  less  distinctness.  A 
similar  difficulty  in  keeping  in  tune  is  experienced  by  performers  on 
certain  musical  instruments.  When  the  conductive  mechanism  is 
subject  to  frequent  alterations  of  tension  in  these  cases,  as  when  the 
membrana  tympani  is  greatly  relaxed,  the  frequent  changes  from 
true  to  false  hearing  are  exceedingly  distressing,  for  at  one  moment 
sounds  strike  on  the  ear  with  a  pleasant  effect,  and  at  the  next  they 


340  AUTOPHONIA. 

seem  muffled;    at  the  same  time  certain  notes,  especially  the  lower 
ones,  produce  a  very  unpleasant  jar  upon  the  ear. 

It  is  well  known  that  some  large  buildings,  in  the  construction  of 
which  wood  largely  enters,  have  a  certain  resonant  quality,  and  the 
timber  at  times  takes  up  musical  notes;  indeed,  every  church  build- 
ing, it  is  said,  responds  to  some  note  of  the  organ,  when  the  whole 
building  will  be  shaken.  The  vibrations  of  the  drum-head  itself, 
when  responding  to  the  notes  of  a  thirty-two-foot  organ-pipe,  may  be 
felt  as  a  succession  of  shocks  rather  than  heard.  The  lower  tones, 
bass  drums  and  brass  instruments,  and  the  rumble  of  heavy  trucks 
in  motion,  are  likewise  sometimes  distressing  to  even  the  normal  ear. 

The  diagnosis  of  autophonia  is  not  always  easily  made,  as  the  phe- 
nomena vary  in  almost  every  case,  and  the  patient's  description  is 
liable  to  mislead.  Owing  to  the  patient's  fancy  respecting  hia 
changed  vocalization,  and  to  the  sympathetic  cough  that  so  often  ac 
companies  aural  affections,  the  patient's  throat  is  likely  to  receive  an- 
undue  share  of  attention  ;  this  fact  should  not  be  overlooked  in  any 
case,  but  in  singers  it  is  important,  for  obvious  reasons,  to  avoid 
any  influence  of  this  kind  in  treatment.  One  important  fact  should 
always  be  kept  in  mind  in  cases  of  false  hearing,  namely,  that  the  phe- 
nomena pertain  almost  exclusively  to  sounds  reaching  the  patient's 
ear  from  within.  Of  course,  if  the  patient  is  so  deaf  that  his  own 
voice  does  not  affect  his  drum-heads  from  without,  he  constantly  hears 
false  in  a  certain  sense,  but  we  are  here  more  particularly  concerned 
with  that  state  where  the  false  hearing  is  of  a  variable  character. 
Such  intermittent  pseudacousma  is  common  during  acute  inflamma- 
tion of  the  middle  ear,  especially  when  the  case  is  recovering,  and 
also  in  certain  chronic  catarrhal  inflammations  of  the  same  region. 
In  these  cases  the  patient,  while  singing,  reading  aloud,  speaking,  or 
playing  certain  instruments,  may  suddenly  hear  the  sounds  produced 
resounding  in  the  head,  while  he  fancies  their  tone  must  be  quite  un- 
natural to  others.  These  unpleasant  symptoms  usually  disappear,  for 
a  time,  as  suddenly  as  they  came,  and  the  increased  deafness  for 
external  sounds,  which  always  exists  while  the  pseudacousma  lasts, 
also  disappears.  The  interruptions  vary  in  their  duration  from  a  few 
seconds  to  days  or  even  months. 

ThQ  prognosis  of  pseudacousma  in  acute  affections  of  the  middle 
ear  is  usually  favorable,  as  normal  hearing  is  re-established  in  a  very 
considerable  number  of  cases,  and  false  hearing  disappears  in  nearly 
all  of  them.  "When,  however,  the  anomaly  occurs  in  the  course  of 
chronic  catarrhal  inflammation  of  the  middle  ear,  it  is  a  very  persist- 
ent symptom.     In  the  cases  where  it  arises  f  ron>  dislodged  collections 


OTHER   ANOMALIES    OF   AUDITION.  341 

of  cerumen  that  impinge  on  the  drum-head,  or  from  foreign  bodies, 
the  removal  of  these  is  usually  sufficient  to  relieve  the  patient. 
With  the  cure  of  furuncles  or  of  diffuse  inflammation  in  the  external 
auditory  meatus,  the  result  is  likewise  favorable. 

As  regards  treatment,  we  can  scarcely  ever  confine  ourselves  to  the 
treatment  of  these  symptoms  alone,  and  after  all  pseudacousma  is 
only  a  symptom  that  may  accompany  many  aural  diseases  ;  any  at- 
tempt in  this  direction  would,  therefore,  carry  the  writer  beyond  the 
scope  of  this  chapter. 

The  successful  treatment  of  any  aural  disease,  however  simple 
its  nature  may  be,  often  depends  on  the  recognition  of  the  value  of 
the  symptoms  here  discussed,  and  we  should  not  fail  to  keep  them  in. 
mind  when  considering  the  management  of  our  cases.  The  absence 
or  presence  of  the  acoustic  symptoms,  pseudacousma  and  tinnitus 
aurium,  is  a  valuable  guide  in  treatment,  although  our  remedies 
should  meet  the  physical  conditions  rather  than  the  acoustic,  know- 
ing as  we  do  that  hearing  will  generally  return  when  the  former  as- 
sume their  wonted  sway. 

CERTAIN   OTHER  ANOMALIES   OP  AUDITION". 

There  are  some  anomalies  of  hearing  that,  to  a  thorough  knowl- 
edge of  this  subject,  should  be  alluded  to,  although  not  classified  with 
false  hearing ;  the  following  are  examples  :  A  gentleman  contracted 
from  sea-bathing  an  otitis  media  serosa  of  the  right  side.  The  exter- 
nal auditory  canals  were  large,  and  in  diving,  water  was  freely  ad- 
mitted to  the  drum-heads,  the  right  one,  on  examination,  being  found 
moderately  hyperaemic.  The  tympanic  cavity  contained  a  consider- 
able quantity  of  serous  fluid,  which  could  be  observed  to  change  its 
position  whenever  the  patient  moved  his  head.  When  the  drum  was 
inflated  with  air  by  Valsalva's  method,  the  fluid  was  thrown  into  bub- 
bles which  lined  the  whole  inner  surface  of  the  membrane.  As  he 
suffered  but  little  pain  or  deafness  from  this  attack,  he  did  not  apply 
for  treatment  until  the  fifth  day  after  getting  the  sea-water  in  his 
ears ;  it  was  at  this  date  that  the  above  observations  were  made. 
His  voice  was  now  autophonous,  and  his  footsteps  jarred  very  plainly 
in  the  right  ear.  He  could  hear  a  low  tone  of  voice  in  both  ears,  but 
the  highest  pipe  of  the  organ  could  not  be  heard  in  the  affected  ear. 
This  gentleman,  when  a  youth,  sometimes  followed  the  hounds.  It 
was  then  well  known  to  all  of  the  hunt  that  he  could  hear  the  dogs 
hetter  than  others  ;  in  fact,  even  after  all  the  rest  had  ceased  to  hear 
them,  if  the  party  kept  quiet  he  could  hear  their  deep  notes  and  also 


342  OTHER    ANOMALIES   OF    ACDITION. 

indicate  the  direction  from  whence  they  came.  He  related  to  the 
writer  another  interesting  experience  ilhistrating  his  wonderful  capac- 
ity to  distinguish  low  tones.  When  boating  in  the  Great  South  Bay, 
L.  I.,  a  few  years  ago  with  some  friends,  he  heard  the  low  peals  of 
thunder  that  accompanied  the  sheet  lightning  then  attracting  their 
attention — a  phenomenon  which  was  inaudible  to  all  of  the  party  but 
himself ;  his  companions  were  aware  of  the  flashing  only.  His  re- 
covery from  the  otitis  media  serosa  was  rapid  and  complete. 

Another  case  of  much  interest  came  to  the  writer's  notice. 

Capt.  Henry  Erben,  U.  S.  N.,  consulted  him  for  a  slight  dis- 
comfort in  the  right  ear,  which  was  found  to  be  due  to  the  presence 
of  some  stiff  hairs  that  had  fallen  into  the  canal  after  having  been 
clipped  off  by  the  barber.  In  conversing  on  the  subject  of  his 
hearing,  Capt.  Erben  informed  the  writer  that  his  perception  of  dis- 
tant sounds  had  always  been  remarkably  acute,  but  that  in  a  large 
hall  or  theatre,  words  spoken  were  not  distinctly  heard ;  sometimes 
the  words  seemed  to  run  together  in  a  confusing  fashion,  and  a  word 
would  be  frequently  lost  altogether. 

Keferring  to  the  distinctness  with  which  he  heard  distant  sounds, 
as  of  the  voice  or  great  guns,  in  a  communication  dated  January  13th, 
1888,  he  said  :  "  In  1862,  when  I  was  on  the  Huntsville  off  Mobile, 
on  blockade  duty,  this  occurred  :  We  had  just  dined  below  and  were 
going  on  deck,  some  eight  officers  of  us,  when  on  reaching  the  upper 
deck  I  heard  the  boom  of  a  great  gun  to  the  westward.  The  sound 
was  distant  to  me,  yet  not  another  officer  heard  it.  Again  and  again 
came  the  sound  to  my  ears,  and  so  certain  was  I  of  the  distant  firing, 
that  the  captain  was  induced  to  order  one  of  the  small  vessels 
of  the  squadron  to  go  in  search.  Finally,  after  a  long  while,  others 
on  the  Huntsville  made  out  the  report  of  guns  and  we  then  also 
went  in  chase.  It  resulted  in  the  capture  of  the  Magnolia,  a  blockade 
runner  with  cotton,  which  had  run  out  of  the  Mississippi  River,  and 
had  been  chased  and  fired  at  by  the  U.  S.  S.  Brooklyn.  Upon 
inquiry,  it  was  found  that  no  one  on  the  other  blockading  vessels  had 
heard  the  Broohlyn's  guns  until  she  was  in  sight  from  aloft.  In 
the  harbor  of  Eio  de  Janeiro,  Brazil,  upon  one  occasion  I  very  plainly 
heard  the  breathing  and  struggling  in  the  water  of  a  man,  to 
which  I  called  the  attention  of  those  on  deck  of  the  Huron,  my 
vessel ;  but  no  one  heard  the  sounds.  A  boat  was  lowered,  however,, 
and  directed  to  pull  in  the  direction  from  which  I  heard  the  sounds 
come,  with  the  result  of  picking  up  a  sailor  who  had  tried  to  swim 
ashore  from  one  of  the  men-of-war,  and  was  nearly  exhausted  when 
found.     Another  instance,  out  of  many  that  I  might  mention,  and  I 


OTHEE   AJSrOMALIES   OF   AUDITIOK.  343 

leave  you  to  draw  your  own  conclusions  as  to  the  acuteness  of  my 
ears  ;  and  I  assure  you  they  have  done  good  service  in  the  direction 
indicated,  while  not  entirely  useless  in  taking  cognizance  of  things 
near  at  hand,  as  sailors'  yarns  for  example. 

"  Off  the  Texan  coast,  of  a  dark  night,  I  heard  the  words  of  com- 
mand given  in  a  low  gruff  tone  of  voice  :  '  Port  your  helm  !  Ahead 
full  speed  ! '  come  from  astern  my  vessel.  None  of  the  others  on 
deck  heard  these  words  ;  hut  in  a  few  moments  a  vessel  ran  past  us 
towards  Galveston,  thus  receiving  our  fire  as  she  passed.  The  inci- 
dent had  passed  out  of  mind,  until  last  summer,  when  I  met  a  person 
who  had  been  aboard  of  this  blockade  runner  at  the  time  ;  they  were 
waiting  until  nearer  midnight  before  attempting  to  run  in,  but  seeing 
the  light  from  a  cigar  on  my  vessel's  deck,  they  determined  to  dash 
past  us.  The  words  of  command  had  been  given  in  an  undertone, 
and  it  was  a  surprise  to  this  gentleman  that  they  had  been  heaid  so 
far. 

"  During  gales  at  sea  I  never  find  it  difficult  to  make  out  what  men 
may  say  from  aloft ;  in  fact,  this  peculiarity  has  long  been  recognized 
by  myself  and  others." 

The  writer  was  surprised  to  find,  on  testing  Capt.  Erben's  hearing 
for  high  notes  with  Konig's  series  of  rods,  that  he  was  unable  to  hear 
any  vibrating  over  20,000  per  second.  The  external  auditory  canals 
and  drum-heads  were  rather  larger  than  usual. 

A  case  reported  by  Dr.  Charles  H.  Burnett  is  also  of  interest.*  The 
patient  was  a  young  lady,  of  musical  acquirements,  who  had  good  hear- 
ing except  for  low  tones,  like  the  bass  notes  of  an  organ,  or  thunder; 
as  regards  the  latter  ''she  first  became  aware  of  her  deficiency  while 
walking  in  the  fields  with  her  father,  for  the  latter  could  distinctly 
hear  the  thunder  of  an  approaching  storm,  "  while  "  she  could  hear 
nothing  of  the  kind."  Dr.  Burnett  does  not  report  any  peculiarity 
in  the  auditory  apparatus  in  this  interesting  case.  In  the  writer's 
own  case  above  noted,  the  drum-membranes  were  among  the  largest 
he  has  ever  seen,  and  slight  inflation  by  Valsalva's  method  caused 
bulging  of  the  drum-membrane  on  both  sides  of  the  malleus  handle. 
The  flapping  membrana  tympani  seem  not  to  affect  the  hearing  for 
ordinary  sounds,  the  tension  of  the  chain  of  ossicles  probably  remain- 
ing intact. 

Attention  has  been  called  by  writers  to  the  fact  that,  in  certain 
cases  where  deafness  exists,  the  patients  could  best  hear  the  notes 
of  the  middle  register  of  the  piano.     The  number  of  observations 

'  Trans,  of  the  American  Otological  Society,  VoL  I.,  page  106. 


344  DYSAC0U8MA. 

having  been  too  few^to  throw  much  light  on  the  subject,  the  author 
determined  to  institute  some  experiments  on  a  considerable  number 
of  patients  at  the  same  time,  and  as  the  piano  was  not  considered  the 
best  instrument  for  the  purpose,  he  requested  Prof.  Mayer,  of  the 
Stevens  Institute  of  Technology,  Hoboken,  to  conduct  some  experi- 
ments with  him  on  a  large  church  organ.  Two  of  the  patients  whose 
hearing  was  tested  on  that  occasion  are  of  interest  here;  they  were 
both  of  them  women  of  about  forty-five  years  of  age,  extremely  deaf 
to  conversation,  from  the  results  of  chronic  catarrhal  inflammation  of 
the  middle  ear.  Neither  of  these  patients  could  distinguish  the 
higher  notes,  but  when  the  middle  register  was  reached  they  could 
plainly  hear  the  notes  sent  forth  by  the  organ.  Below  the  middle 
register  these  patients  heard  no  sound  again  until  the  lower  notes 
were  sounded;  these  were  heard  by  both  of  them.  The  experiences  of 
others  present  on  this  occasion  seemed  to  confirm  the  observation 
respecting  the  capability  of  some  individuals  to  hear  the  middle 
register  best;  one  of  them,  a  gentleman  of  musical  education,  al- 
though hearing  all  the  notes  in  some  degree,  found  that  those  of  the 
middle  register  were  heard  most  distinctly.  The  following  case  is 
another  example  :  A  piano-tuner,  fifty  years  of  age,  who  had  been 
thus  employed  for  twenty-five  years,  gradually  became  quite  deaf;  it 
was  finally  ascertained  that  in  tuning  a  piano,  after  passing  above  the 
middle,  he  began  to  sharpen  up  to  the  end  of  the  scale — in  the  three 
octaves  he  sharpened  a  fifth.  This,  of  course,  did  not  fail  to  dis- 
satisfy the  customers  of  the  establishment  that  employed  him,  and 
he  had  to  give  up  his  occupation. 

It  should  be  stated  that  musicians  with  advancing  deafness,  after 
a  while  find  that  slight  differences  in  the  loudness  of  tones  near  the 
middle  of  the  musical  scale  are  not  easily  recognized. 

Facts  like  these  seem  to  confirm  the  physiological  theory  used  in 
explanation  of  these  anomalies,  namely,  that  in  such  cases  there  must 
be  some  pathological  change  in  the  cochlea.  Inquiries  of  practical 
musicians,  however,  elicit  the  statement  that  the  cornet  or  reed  stop 
of  the  organ  is  the  clearest  and  most  natural  in  the  scale,  and,  there- 
fore, most  easily  heard.  On  the  piano,  middle  C  is  the  equivalent  of 
this,  which  accounts  for  its  being  heard  better  in  certain  cases. 

DYSACOUSMA. 

Painful  hearing  or  hypercesthesia  acoustica,  as  it  is  sometimes 
called,  is  due  to  cerebral  exhaustion,  hypersemia,  or  inflammation  of 
the  brain,  whereby  the   organ  becomes   sensitive  to  impressions  of 


DYSACOUSMA.  345 

sound,  as  some  regions,  when  inflamed,  are  painful  to  touch.  Im- 
pressions of  sound  upon  the  nervous  centre  when  in  a  state  of  ex- 
citability, as  in  persons  suffering  from  nervous  exhaustion,  or  in 
lepto-  or  pachymengitis,  may  be  excruciating  in  the  extreme. 

The  employment  of  the  term  "  hyperaesthesia  acoustica"in  this 
connection  is  liable  to  lead  to  confusion,  inasmuch  as  it  implies  that 
acuity  of  the  auditory  function  of  the  nerve  of  hearing  may  be  in- 
creased by  irritation  or  inflammatory  action.  The  writer  cannot 
admit  that  the  auditory  function  of  this  nerve  can  be  increased 
beyond  the  normal  state,  although  it  is  plain  that  pathological 
changes  may  impair  its  action.  There  seems  to  be  no  good  reason 
why  sensory  impulses,  however,  may  not  be  transmitted  along  its 
tract  through  flbres  of  the  portio  dura.  The  writer  has  witnessed 
central  disturbance  when  the  chorda  tympani  or  other  nervous  fila- 
ments distributed  to  the  external  or  middle  ear  have  been  irritated. 
Physiologists  have  not  admitted  that  the  auditory  nerve  has  the  dual 
function  of  transmitting  sensory  as  well  as  sound  impressions,  and 
some  writers  have  endeavored  to  overcome  the  difficulty  by  supposing 
the  existence  of  separate  nerve  fibres  accompanying  the  auditory 
nerve  from  the  ear  to  the  brain.  We  must  not  overlook  the  fact, 
however,  that  the  situation  of  the  auditory  nerve  precludes  its  as- 
suming sensory  functions  ordinarily. 

The  following  is  a  case  in  point: 

Patient,  a  female,  aged  33  years,  married  and  has  borne  several 
■children.  Her  father,  mother,  a  brother,  and  a  sister  died  of  phthisis 
pulmonum.  For  the  past  year  she  has  had  much  domestic  trouble. 
She  has  had  a  purulent  discharge  from  the  right  ear  since  childhood. 
All  her  upper  teeth,  excepting  the  first  right  bicuspid,  a  carious  fang 
of  which  now  remains,  are  gone.  This  fang  is  the  cause  of  an 
alveolar  abscess  which  had  existed  for  some  time.  She  has  worn  a 
full  upper  vulcanite  plate  of  false  teeth  for  several  years,  and  its 
pressure  on  the  fang  mentioned  has  of  late  caused  sufficient  reflex 
irritation  in  the  right  ear  to  kindle  an  extensive  acute  inflammation 
of  the  connective  tissue  in  that  region,  accompanied  by  severe 
neuralgic  pains  extending  deeply  into  the  temporal  region.  Pressure 
on  the  fang  causes  pain  in  the  ear.  Only  a  portion  of  the  membrana 
tympani  now  remains,  and  there  is  some  pus  in  the  drum.  The 
present  attack  began  on  November  13th,  1880,  the  pains  being  so 
great  that  the  patient  could  not  sleep  or  rest  during  the  two  days 
preceding  the  author's  examination,  made  November  15th.  On  dis- 
<50very  of  the  alveolar  abscess,  the  patient  at  once  became  aware  that 
the  principal  seat  of  the  pains  was  in  the  right  upper  jaw;  but  the 
pains  in  the  head  increased  rapidly  and  on  November  16th  she  began 
to  experience  vertigo  and  nausea  to  a  distressing  extent,  and  stag- 
gered greatly  when  endeavoring  to  walk.     The  patient  now  says  that 


346  DY8ACOU8MA. 

sounds  affect  her  very  much;  the  rattling  of  silver  or  plates  on  a 
marble-top  table,  or  the  heavy  rumbling  noises  heard  when  she  is 
on  the  street,  give  her  intense  pains  in  the  forehead,  and  make  her 
tired.  It  was  found  on  instituting  inquiries  that  the  sensitiveness 
to  noises  heard  only  occurs  when  the  left  or  normal  ear  is  open; 
when  the  loudest  sounds  of  the  voice  are  conveyed  to  the  affected 
ear  through  a  tube,  she  hears  them  imperfectly,  but  they  do  not 
give  rise  to  pain.  The  clashing  of  steel  is  not  painful  so  long  as 
the  sound  ear  remains  closed,  but  the  moment  these  noises  are  ad- 
mitted through  the  latter,  they  give  rise  to  severe  pains  in  the  fore- 
head. Such  sounds  are.  however,  it  should  be  said,  heard  normally. 
She  is  much  exhausted  by  these  experiments  and  says  she  feels  very 
tired  in  the  head.  The  patient  could,  to  some  extent,  feel  the  im- 
pressions of  sound  when  both  ears  are  closed;  they  seemed  to  "  strike 
the  bram,^'  as  she  herself  expressed  it,  the  sensitive  spot  being  in  the 
forehead. 

Patient  was  physically  well  nourished,  although  she  had  been  ill 
for  a  long  time. 

It  would  thus  seem  that  the  sensitiveness  to  sound  in  cases  like  the 
above,  where  irritation  of  the  brain  and  its  meninges  certainly  existed, 
is  located  in  the  brain,  not  in  the  ear. 

In  dysacousma,  the  ears,  however,  may  be  unaffected  or  even  closed, 
so  as  to  exclude  sound,  and  yet  the  impact  of  certain  noises  may  pro- 
duce painful  impressions  upon  the  brain,  as  though  it  had  been  '*  struck 
by  a  blow.''  The  brain  in  some  totally  deaf  persons  is  painfully  af- 
fected by  certain  sounds,  as  of  thunder  or  the  low  tones  of  an  organ- 
pipe,  whilst  others  cannot  endure  whispered  sounds  made  directly 
into  the  ear;  the  cause  of  which  would  seem  to  be  that  the  perceptive 
centre  of  the  deaf  is  unaccustomed  to  any  invasion  of  sound. 

Sounds  of  low  pitch  undergo  a  modification  in  certain  cases  of 
acute  inflammation  of  the  middle  ear;  thus  the  low,  heavy  undulations 
of  street  trucks,  elevated  railroad  carriages,  and  the  like  are  heard  as 
high  in  pitch,  sometimes  like  a  whistle.  This  condition  is  entirely 
distinct  from  that  giving  rise  to  painful  perceptions  of  sound;  it  is 
due  to  disturbance  of  equilibrium  in  the  transmitting  mechanism, 
whereby  its  tension  is  probably  increased,  since  it  occurs  in  the  course 
of  acute  inflammation  of  the  middle  ear  and  in  the  profound  deafness 
due  to  syphilis.  Of  course,  the  impact  of  sounds  of  low  pitch,  when 
heard  as  high,  may  give  rise  to  painful  sensations  in  nervous  persons. 

Of  interest  in  explaining  anomalous  action  of  the  transmitting 
mechanism  is  the  behavior  of  the  telephonic  diaphragm.  On  calling 
the  attention  of  Prof.  Graham  Bell  to  this  subject,  he  referred  to  the 
experiments  made  under  his  own  direction  by  Mr.  Thomas  A.  Watson, 
of  Weymouth,  Mass.,  in  1882.     Mr.  Watson,  in  a  letter  dated  October 


DY8AC0USMA.  34:T 

4th,  1884,  informs  the  writer  that  sound  from  a  bent  or  dented 
telephone  diaphragm  is  diminished  in  volume,  seemingly  in  proportion 
to  the  extent  of  the  injury,  and  is  often  accompanied  by  a  ringing 
overtone.  A  striking  illustration  of  this  was  afforded  by  an  experi- 
ment. A  thin  iron  diaphragm,  much  damaged  by  inverting  its  edge 
all  around,  was  pressed  into  a  solid  metal  ring,  so  that  its  surface 
took  the  form  of  a  shallow  cup.  The  effect  was  always  to  render  the 
sound  very  feeble,  without  giving  any  overtone.  When  a  hole  of 
one-third  to  one-eighth  inch  in  diameter  was  made  through  a  tele- 
phone diaphragm,  sound  was  unaffected  or  become  even  a  little  clearer. 
"  The  vibrations  of  a  telephone  diaphragm  are  always  accompanied 
by  an  overtone  which  varies  with  its  thickness,  becoming  lower  as 
this  is  diminished." 

Straining  a  membranous  diaphragm  similar  to  the  drum-head  raises 
the  pitch  of  the  overtone.  It  was  found  that  sound  diminished  in 
volume  (amplitude)  very  rapidly,  as  the  magnet  was  withdrawn  from 
the  diaphragm,  though  its  quality  (pitch)  remained  unchanged.  The 
effect  of  a  lai'ge  cavity  between  the  diaphragm  and  the  inner  surface 
of  the  plate,  forming  the  mouth  piece,  is  to  add  to  the  sound  a  strong 
overtone,  due  to  the  excessive  reinforcement  of  a  particular  pitch  of 
this  resonating  cavity. 

Sound  thus  undergoes  modification  during  its  transmission  through, 
a  defective  telephone,  and  from  the  similarity  of  this  instrument  to 
the  ear,  we  should  expect  that  like  changes  would  occur  on  its  trans- 
mission through  a  defective  ear-drum.  Clinical  observation  shows 
this  to  be  the  case  where  mucus  or  other  fluid  accumulates  in  the 
drum  during  inflammation,  or  when  the  drum-head  is  swollen  or 
thickened  by  means  of  a  covering  of  exfoliative  dermic  tissue;  or 
where  its  tension  is  disturbed  from  any  cause,  such  as  manometric 
cicatrices  or  opacities,  ankylosis  of  the  ossicles  to  each  other  or  to  the 
walls  of  the  drum,  and  the  relaxation  or  separation  of  their  attach- 
ments, etc.  Whilst,  on  the  one  hand,  resonance  of  the  drum  may  be 
altered  by  distention  of  fluids,  and  possibly  by  air  or  gases,  it  may  be 
due,  on  the  other  hand,  to  the  absence  of  the  normal  humidity  of  the 
drum,  or  retraction  of  the  drum  head  from  closure  of  the  Eustachian 
tube. 


348  AURAL   PHENOMENA    AND    BRAIN   AFFECTIONS. 

SOME   OF  THE   RELATIONS   OF   CERTAIN    AURAL   PHE- 
NOMENA,   HALLUCINATIONS,    ETC.,    TO    IN- 
SANITY   AND    BRA.IN    AFFECTIONS. 

It  is  well  known  that  certain  individuals  are  unpleasantly  affected 
I)y  hearing  slight  sounds,  as  the  crumpling  of  paper,  the  ticking  of  a 
clock,  and  the  like,  and  that  they  are  annoyed  or  startled  by  noises 
that  strike  upon  the  ear  unexpectedly.  Such  persons  are  often  greatly 
affected  by  disturbances  of  audition  to  which  others  attach  but  little  im- 
portance. These  people  we  designate  by  the  familiar  term  of  "nervous," 
and  in  this  age  of  mental  strain  and  over-excitement  they  compose  a 
large  class.  The  special  sense  of  hearing  may,  therefore,  afford  the 
first  intimation  by  which  we  may  obtain  a  knowledge  of  the  existence 
of  nervous  diseases,  and  the  study  of  their  relations  to  the  brain  is, 
therefore,  one  of  great  importance. 

The  writer  desires  to  draw  attention  to  some  of  the  observations  he 
has  made  in  cases  where  the  aural  symptoms  seemed  to  exert  an  in- 
fluence in  exciting  nervous  phenomena;  where,  for  example,  noises  in 
the  head  have  created  so  much  distress  that  actual  insanity  has 
seemed  to  threaten,  or  where,  in  other  instances,  inflammation  of  the 
brain  or  its  meninges  has  occurred,  along  with  the  intense  neuralgia 
associated  with  these  diseases.  "Where,  therefore,  a  predisposition  to 
alienation  exists,  or  where  this  state  has  become  established,  the  in- 
fluence that  aural  affection  would  exert  upon  the  diagnosis,  progno- 
sis, and  treatment  should  not  be  overlooked. 

From  the  cases  given  in  connection  with  this  subject,  it  will  be 
seen  that,  what  are  called  subjective  noises,  exert,  under  certain  con- 
ditions, a  not  unimportant  influence  on  the  mind.  It  should  be  kept 
in  view,  however,  that  the  noises  called  subjective  have  an  actual  ex- 
istence and  always  depend  on  physical  causes.  That  tbe  over- 
excited brain  or  the  superstitious  mind  may  experience  a  psychical 
introversion,  as  regards  the  perception  of  these  sounds,  and  thus 
mould  them  to  suit  the  morbid  fancies  of  the  mind,  in  a  given  case, 
can  well  deserve  belief.  The  insane  know  that  they  hear  certain 
noises  which  others  do  not  hear,  and  efforts  to  dissuade  them  from 
this  belief  may  be,  under  some  circumstances,  unwise.  It  is  a  long 
time  since  the  insane  were  observed  to  stuff  wool  and  the  like  into  their 
ears,  but  it  is  believed  that  the  observation  has  never  led  to  a  thorough 
study  of  the  subject.  It  is  not  uncommon  to  find  the  ears  of  the  sane 
obstructed  by  pellets  of  cotton  wool,  inserted  to  exclude  the  "  noises 
in  the  ears."    These  foreign  matters,  when  left  in  the  ears,  become 


ATJEAL    PHENOMENA    AND    BKAIN   AFFECTIONS.  349 

frequently  enveloped  in  cerumen  and  go  on  increasing  in  size  from 
year  to  year.  When  pressure  is  exerted  on  the  membrana  tympani 
by  such  collections,  the  tinnitus  aurium  is  much  increased,  and  very 
frequently  autophony  manifests  itself.  Sometimes  deafness  is  thus 
induced,  which,  of  course,  adds  very  much  to  the  despondency  of 
the  patient,  and  increases  his  distrust  of  others.  Patients  who  ex- 
perience false  hearing  or  autophony,  and  have  at  the  same  time  dis- 
tressing noises  in  the  ears  and  head,  are,  even  when  otherwise  healthy, 
under  a  great  mental  strain,  and  are  frequently  found  struggling  with 
all  their  strength  against  their  misfortunes.  Old  persons  often  give 
way  entirely  to  these  depressing  influences,  living  in  a  state  of  constant 
alarm;  their  condition  is  not  understood  by  others,  nor  can  they 
always  explain  their  own  sensations. 

The  character  of  these  sounds  in  the  ears  has  been  described  in  an- 
other place,  and  will  not  be  enumerated  here.  There  is  scarcely  a 
sound  in  natural  or  industrial  life  that  some  patient  or  another  can- 
not find  its  resemblance  in  the  noises  sometimes  heard  by  them  in  the 
head. 

These  sounds  are  sometimes  thought  to  indicate  the  presence  of 
tumors  in  the  ears,  and  the  brain  itself  is  often  suspected  of  being  the 
seat  of  a  tumor.  In  many  of  these  cases,  an  increase  of  excitement 
increases  all  the  symptoms,  especially  those  depending  on  the  sounds 
of  the  blood  in  its  circulation.  It  is  stated,  the  writer  believes,  that 
insanity  is  not  a  disease  of  youth;  it  is  also  true  that  the  more  dis- 
tressing aural  diseases  are  mostly  to  be  found  after  middle  life,  for  it 
is  at  that  period  that  we  find  the  drum-head  relaxed  and  the  normal 
tension  of  the  ossicles  disturbed — conditions  less  remediable  than  the 
more  acute  affections  of  youth.  It  is  then  that  the  most  bewildering 
phenomenon  of  autophony  is  frequently  experienced;  and  one  may 
add  here,  that  but  few  sufferers  are  capable  of  describing  this  condi- 
tion. These  acoustic  phenomena  become  more  observable  at  night  when 
quiet  prevails;  then  every  sound  within  the  body,  including  the  voice, 
sounds  of  the  heart,  and  respiratory  movements  are  heard  with  appal- 
ling distinctness.  Slight  movements  in  the  conductive  mechanism  of 
the  middle  ear,  such  as  occur  from  breathing,  swallowing,  etc.,  are 
liable  to  cause  a  sudden  variation  in  these  phenomena.  One  moment, 
the  patient,  in  speaking  or  reading  aloud,  hears  his  own  voice  in  the 
normal  manner;  the  next  moment,  he  only  hears  the  altered  voice 
within  his  head.  The  effect  of  these  experiences  on  certain  minds  can 
be  well  understood.  In  this  connection,  it  should  be,  furthermore, 
mentioned  that  persons  are  liable  to  be  very  much  disturbed,  when 
affected  with  the  anomalies  under  consideration,  by  lying  on  the  ear 


350  AURAL    PHENOMENA    AND    BRAIN    AFFECTIONS. 

when  in  bed.  Trobbings  are  then  more  often  experienced,  and  some- 
times even  the  crushing  down  of  the  pillow  contributes  to  the  sounds 
heard.  From  what  has  been  said  it  will,  therefore,  be  seen  that  affec- 
tions of  the  ear  may  give  rise  to  nervous  diseases,  and  when  a  predis- 
posing cause  exists,  insanity  itself  may  be  induced.  Mental  depres- 
sion they  always  occasion  in  the  aged,  and  but  few  sufferers  escape 
despondency  and  distrust  of  their  fellows. 
The  following  cases  are  illustrative: 

Case  1. — Mrs.  A.  M.,  aged  25,  consulted  the  writer  in  November, 
1880,  on  account  of  deafness.  She  was  confined  five  years  ago,  since 
which  time  her  health  has  not  been  as  good  as  it  was  previously. 
She  has  noticed  that  she  was  becoming  deaf  for  the  past  two  years. 
The  tonsils  are  ragged,  she  has  naso-pharyngeal  catarrh,  and  has  ex- 
perienced a  great  amount  of  dental  irritation,  especially  during  the 
winter  of  1878-9.  The  upper  wisdom  teeth  were  extracted  in  1878. 
The  gum  about  the  right  inferior  wisdom  tooth  has  for  two  years  been 
the  seat  of  alveolar  abscesses.  The  patient  has  even  at  times  been 
obliged  to  keep  her  bed  on  this  account. 

There  has  been  tinnitus  aurium  in  the  right  ear  for  some  time  past, 
and  she  hears  occasionally  her  own  voice  autophonously — as  she  her- 
self describes  it,  her  head  "  seems  hollow,''  and  she  then  feels 
*'  dumb."  This  experience  was  associated  by  the  patient  with  a  loss 
of  memory,  and  for  a  while  she  restrained  herself  from  speaking. 
When  she  is  excited  the  ringing  in  her  ears  is  much  increased,  and 
she  sometimes  hears  the  tinkling  of  bells. 

She  hears  the  voice  only  when  shouted  in  the  right  ear.  In  the 
left  ear  she  hears  no  words  spoken  below  the  ordinary  tone. 

This  patient  has  experienced  a  great  deal  of  domestic  trouble, 
which,  together  with  the  facial  neuralgia  resulting  from  the  diseased 
condition  of  the  teeth,  the  tinnitus  aurium,  and  the  autophony, 
finally  excited  an  attack  of  dementia.  The  neurologist  to  whom  the 
patient  was  taken  for  treatment  informed  the  writer  that  her  attacks 
were  simply  rage,  that  she  had  always  been  on  the  verge  of  insanity, 
and  is  likely  to  become  hopelessly  insane. 

Whatever  the  diagnosis  or  prognosis  of  this  case  may  be,  its  history 
certainly  shows  the  importance  of  early  attention  being  given  to  the 
aural  symptoms  in  all  such  cases.  The  authoB  is  inclined  to  believe 
that  skilful  treatment  of  the  teeth  in  this  case  would  have  done  some- 
thing towards  preventing  the  progress  of  the  deafness.  It  certainly 
would  have  cured  the  neuralgia  which  caused  so  much  irritation  about 
the  head.  The  tinnitus  and  autophony  alone  were  sufficient  to 
greatly  disturb  the  mind. 

[This  patient  gradually  improved,  and  gave  no  evidence  of  any 
mental  disturbance  until  the  summer  of  1887,  when  a  disposition  was 


AUEAL    PHENOMENA    AND    BRAIN   AFFECTIONS.  351 

sliowu  on  one  occasion  to  give  way  to  rage  on  account  of  domestic 
difficulties.] 

Case  2. — Male,  aged  59  years,  came  under  observation  in  September, 
1878;  a  tailor  by  occupation,  thin,  and  with  sallow  complexion.  He 
had  in  his  childhood  disease  of  the  knee-joint,  and  since  then  has 
been  lame.  Twenty-five  years  ago  he  had  pains  in  the  right  ear,  fol- 
lowed by  more  or  less  discharge,  and  great  deafness.  He  has  now 
very  severe  pains  in  the  region  of  the  right  ear,  extending  over  the 
whole  temporal  space,  and  which  prevents  sleep  at  night.  His  family 
gave  the  information  that  his  suffering  is  so  great  at  times  that  he 
often  expresses  the  intention  of  committing  suicide.  Three  years 
ago  he  had  an  attack  of  vertigo,  also  a  similar  one  a  year  ago.  Dur- 
ing these  attacks,  he  experienced  much  pain,  and  staggered  like  a 
drunken  man,  sometimes  falling  down.  His  teeth  have  long  been 
the  seat  of  alveolar  abscesses,  from  which  there  has  been  swelling 
about  the  right  side  of  the  face,  the  pains  often  extending  from 
the  teeth  to  the  ears.  The  present  condition  of  his  teeth  is  a 
wretched  one,  the  few  remaining  ones  being  denuded  and  loose.  The 
right  ear  is  found  to  be  occupied  by  a  large  polypoid  growth,  spring- 
ing from  the  lower  wall  of  the  canal.  A  discharge  also  exists.  When 
the  polypus  was  removed,  it  was  found  that  a  large,  irregular  growth, 
large  and  fleshy-looking,  closed  the  canal  just  without  the  tympanum. 
Attempts  to  remove  this  with  the  snare  were  unsuccessful,  and  the 
patient  declined  to  have  it  removed  by  the  drill;  also  to  have  his  teeth 
attended  to.  There  was  no  evidence  of  the  existence  of  mastoid 
disease. 

He  was  not  seen  again  until  July,  1879,  when  it  was  learned  that 
after  the  removal  of  the  polypus,  his  condition  had  very  much  im- 
proved, with  the  exception  of  the  deafness,  now  very  great.  He  can 
only  hear  words  shouted  into  the  right  ear.  Patient  suffered  much 
from  pains  and  the  acoustic  phenomena,  autophony,  and  tinnitus. 
Soon  after  his  last  visit  the  discharge  from  the  right  ear  ceased,  but 
the  pains  and  tinnitus  continued,  and  the  left  ear  also  became  pain- 
ful. He  died  in  July,  1880.  Two  months  before  his  death  he  grew 
very  deaf  in  the  left  ear.  The  pains  and  tinnitus  in  both  ears  became 
so  unbearable  that  he  tried  to  hang  himself  to  escape  from  the  terri- 
ble suffering.  The  family  did  not  consider  him  to  be  insane,  but 
concluded  to  send  him  to  the  New  York  City  Insane  Asylum,  where 
he  was  admitted  in  February,  1880. 

Case  3. — Female  patient,  aged  39  years,  married;  no  children. 
There  is  no  history  of  miscarriages.  She  has  always  suffered  from 
**  colds  "  and  toothaches.  Has  been  addicted  to  the  use  of  alcohol  for 
many  years.  No  previous  aural  trouble,  excepting  a  slight  attack  of 
earache  in  the  left  ear  three  years  ago.  Tinnitus  like  "  buzzing  "  be- 
gan in  the  left  ear  about  a  year  ago,  but  was  unaccompanied  by  any 
deafness.  Patient  states  that  her  "  head  began  to  feel  badly  "  some 
time  ago,  and  her  eyes  troubled  her.  About  ten  weeks  si  nee,  she  says, 
she  suddenly  heard  the  voice  of  deceased  persons  speaking  to  her  in 
her  left  ear.     These  voices  were  both  male  and  female.     Since  then 


352  AURAL   PHENOMENA   AND    BRAIN    AFFECTIONS. 

the  satne  thing  occurs  daily,  the  voices  using  often  profane  and 
obscene  language,  and  calling  her  bad  names.  She  hears  also  music, 
singing,  etc.  She  is  annoyed  by  tinnitus  aurium  and  autophonous 
voice.  Patient  is  fully  persuaded  that  the  voices  she  hears  proceed 
from  some  individual,  and  not  from  her  own  ears.  The  language  has. 
become  much  more  abusive  of  late,  she  says,  and  within  the  past 
two  weeks  the  hearing  in  the  left  ear  has  diminished  very  considera- 
bly. In  consequence  of  these  subjective  symptoms,  patient  has  lost 
her  appetite,  become  emaciated,  and  mentally  much  depressed.  She 
sits  for  long  periods  staring  vacantly  before  her.  Her  eyesight  is 
very  poor.  She  has  also  vomiting  in  the  morning.  Her  right  ear  does 
not  trouble  her  at  all. 

Examination.  Left  membrana  tympani  is  dull-looking  and  opaque, 
especially  in  the  posterior  inferior  segment,  and  retracted.  The  short 
process  is  prominent.     The  membrana  flaccida  is  hyperaemic. 

The  right  membrana  tympani  is  somewhat  retracted,  but  of  fair 
lustre.     Hears  low,  ordinary  voice  at  several  feet  in  both  ears. 

Eyes.  On  examining  the  fundus  of  the  right  eye,  the  vessels  arfr 
seen  to  be  fuller  than  normal;  the  inner  end  of  the  disc  is  indistinct 
and  blurred.  In  the  fundus  of  the  left  eye,  nothing  abnormal,  to  all 
appearances. 

The  pharynx  is  congested,  and  there  are  several  carious  teeth  in  the 
jaws. 

Case  4. — Male  patient,  aged  40  years,  came  to  the  New  York  Eye 
and  Ear  Infirmary  in  November,  1880.  He  was  a  laborer,  employed 
by  a  horse-car  company  as  a  driver.  He  has  a  dark  visage,  and  his 
eyes,  in  looking  at  one,  suggest  that  he  is  distrustful  and  has  a  capa- 
bility for  irresponsible  acts.  He  stated  that  one  year  ago  he  had  a- 
severe  attack  of  delirium  tremens,  which  kept  him  confined  in  a  hos- 
pital for  two  months.  For  some  time  past,  however,  he  has  been  tem- 
perate. He  is  forgetful  and  nervous,  gets  easily  excited  about  trivial 
affairs. 

An  examination  of  the  oral  and  naso-pharyngeal  cavities  showed 
the  existence  of  very  carious  teeth  and  a  general  catarrhal  condition 
of  these  parts.  The  3rum-heads  were  both  hyperaemic  in  the  neigh- 
borhood of  the  anterior  superior  quadrant.  They  were  mottled  in 
appearance,  and  exhibited  evidences  of  trophic  changes.  The  con- 
dition of  the  left  ear  was  the  most  marked. 

His  hearing  is  good;  he  can  distinguish  low  conversation  in  both, 
ears.     In  his  left  ear  he  experiences  a  constant  "whiz." 

For  the  past  six  months,  he  fancies  that  some  one  is  talking  to  him 
every  night,  the  voice  seeming  to  enter  the  left  ear.  He  is  kept 
awake  a  long  time  by  the  voice,  which  repeats  over  and  over  again: 
"  Get  up  !  won't  let  you  sleep  !  "  or  at  other  times:  "  You  damned 
scoundrel,''  "  I'll  kill  you  !  "  etc.  Such  expressions  are  rarely  expe- 
rienced in  the  daytime  unless  when  it  is  very  quiet.  While  the 
•writer  was  examining  the  patient,  the  latter  told  him  that  the  voice 
said  "that  doctor  can  do  you  no  good  !  " 

When  it  was  explained  to  the  patient  that  the  noises  proceeded 
from  natural  causes,  such  as  the  current  of  blood  in  the  carotid  canal. 


ATJEAL   PHENOMENA   AND   BRAIN   AFFECTIONS.  353 

lie  was  totally  unable  to  disconnect  them  from  the  supernatural. 
When  seen  some  weeks  later,  the  condition  of  this  patient  was  proba- 
bly worse  than  when  he  was  first  seen.  That  the  noises  in  the  head 
had  an  unfavorable  influence  upon  this  case  there  can  be  no  doubt. 

Case  5. — Mary  D ,  38  years  of  age,  came  to  the  N.  Y.  Eye  and 

Ear  Infirmary  in  January,  1880.  She  is  married  and  has  had  six  chil- 
dren. Patient  is  a  very  tall  and  large  woman,  weighing  over  two 
hundred  pounds.  She  states  that  her  weight  has  been  considerably 
greater,  but  that  from  poor  living  of  late  it  has  been  reduced.  In  an 
altercation  a  week  ago  with  a  man,  for  whom  she  had  done  some 
washing,  she  received  a  blow  upon  the  right  ear  with  the  fist,  from 
the  stunning  effects  of  which  she  recovered  in  a  few  minutes  to  find 
that  there  was  a  noise,  like  escaping  steam,  in  the  injured  ear,  and 
that  she  was  very  dizzy.  The  tinnitus  aurium  has  continued  until 
the  present  time,  and  after  the  fourth  day  the  vertigo  was  so  great 
that  she  could  no  longer  attend  to  her  domestic  duties.  On  the  fifth 
day,  there  was  a  free  serous  discharge  which  she  had  not  previously 
observed,  and  this  gradually  gave  place  to  a  copious  one  of  a  muco- 
purulent character. 

The  discharge  is  now  tinged  with  blood  and  so  free  that  a  large 
pellet  of  cotton-wool  soon  becomes  saturated  with  it,  and  it  runs  down 
the  side  of  the  neck.  She  had  no  medical  attendance  until  the  sixth 
day  after  the  injury,  when  she  was  taken  to  a  dispensary,  where  some 
medicament  was  put  into  the  ear  and  the  drums  were  inflated  by 
means  of  an  air-bag.  She  states  that  the  local  application  seemc'l  to 
irritate  theear,  and  that  the  air  douche  increased  the  pains  very  much. 
The  day  following  the  above  treatment  she  was  brought  to  the  author's 
clinic.  Her  condition  then  was  as  follows  :  She  was  very  excitable, 
and  feared  to  have  the  ear  examined,  but  submitted  after  a  little 
coaxing.  The  right  ear  was  discharging  freely,  as  has  been  stated. 
After  this  had  been  wiped  out,  it  was  ifound  that  the  parts  were  so 
swollen  that  the  precise  point  of  rupture  in  the  membrane  could  not 
be  located.  There  was  some  swelling  about  the  attachment  of  the 
auricle,  and  the  parts  were  painful  when  touched.  She  has  severe 
neuralgic  pains  in  the  temporal  region.  The  first  right  upper  molar 
tooth  is  very  carious.  Her  voice  was  autophonous,  and  she  could 
hear  shouted  words  only  in  the  affected  ear.  From  her  husband  and 
herself  the  following  facts  were  obtained.  The  night  before  her  visit 
to  the  infirmary,  she  retired  about  nine  o'clock,  but  was  unable  to 
sleep  ;  she  was  restless,  and  obliged  her  husband  to  get  up  constantly 
during  the  night  to  look  after  the  many  hallucinations  that  occupied 
her  mind.  She  required  him  to  keep  the  window  of  the  room  open 
all  night  that  he  could  watch  the  yard  below,  which  she  believed  to  be 
filled  with  people  who  sought  to  kill  both  herself  and  her  husband. 
At  times  she  fancied  there  were  persons  speaking  fropi  the  walls — she 
would  then  stand  for  a  while  in  a  listening  attitude.  A  man  dressed 
in  white  came  up  out  of  the  floor  and  stood  near  the  door  and  held  a 
club,  as  if  about  to  strike  ;  although  a  light  was  burning  in  the  room 
at  the  time,  she  cannot  recall  seeing  his  face. 

She  also  saw  young  women  in  white  attire.  The  voices  were  not 
23 


354  AURAL   PHENOMENA    AND    BRAIN    AFFECTIONS. 

recognized,  excepting  she  fancied  that  among  those  in  the  yard  she 
could  hear  the  voice  of  the  man  who  struck  her,  and  also  the  voice  of 
his  wife.  She  sometimes  exclaimed  to  her  husband:  "  There  I  they 
are  coming  up  the  stairs  ! " 

She  seemed  to  see  objects  flitting  about,  and  when  this  was 
doubted,  she  would  exclaim.  "  don't  I  see  them  ! "  These  objects  are 
not  seen  during  the  day.  She  was  afraid  to  remain  alone,  and  to-day 
the  assistance  of  a  policeman  was  required  to  bring  her  to  the  infir- 
mary. It  is  stated  that  she  has  never  experienced  any  mental  aberra- 
tion nor  have  any  of  her  relations.  There  was  no  dysacousma  experi- 
enced at  this  time  or  subsequently. 

This  patient  remained  under  observation  until  February  26th,  after 
wlhich  time  she  was  not  seen.  For  some  time  after  her  first  visit,  her 
sleep  was  accompanied  by  dreams  of  music,  of  ships  and  of  soldiers 
and  the  like,  and  it  was  more  than  two  weeks  before  she  ceased  to 
experience  the  hallucinations. 

The  pain  in  the  region  of  the  ear  was  severe  for  ten  days  and  at  one 
time  extended  to  other  parts  of  the  head.  The  discharge  from  the 
ear  had  almost  ceased,  she  had  but  little  tinnitus  aurium  or  auto- 
phony,  the  swelling  of  the  external  auditory  meatus  disappeared,  and 
a  small  air  bubble  marked  the  seat  of  perforation  at  the  inferior  seg- 
ment of  the  membrane  tympani  ;  the  latter,  however,  was  still  indis- 
tinguishable on  account  of  its  sodden  condition.  Hearing  returned 
so  that  she  could  hear  loud  voice,  and  the  vertigo  was  very  slight. 

Inasmuch  as  dysacousma  was  not  a  symptom  in  this  case,  it  is  be- 
lieved that  the  brain  itself  was  not  greatly  affected  by  the  concussion 
of  the  blow  nor  by  an  extension  of  the  inflammation. 

Case  6. — The  patient,  an  Irishman,  40  years  of  age,  states  that  he 
has  long  been  of  intemperate  habits.  He  has  been  subject  to  "  dry 
throat"  in  the  morning,  to  frequent  headaches,  and  is  nervous  and 
"  shaky."  He  stated,  when  he  came  to  the  New  York  Eye  and  Ear 
Infirmary  in  December,  1885,  that  seven  months  previously,  after  a 
severe  "  spree,"  he  had  delirium  tremens,  and  on  recovery  experi- 
enced annoying  sounds  in  the  left  ear ;  persons  either  seemed  to  be 
"  talking  to  him  constantly  "  or  there  were  sounds  of  voices  in  this 
ear.  At  first  he  thought  the  voices  heard  were  those  of  persons  fol- 
lowing him  about  "for  the  sake  of  a  joke,"  but  of  late  he  believes 
they  may  be  due  to  some  disease  of  the  ear.  As  regards  the  tinnitus, 
he  describes  a  "beating"  sound  in  the  ear  synchronous  with  the 
cardiac  pulsation,  and  a  "buzzing."  Sometimes  there  is  low  whis- 
tling. There  has  been  no  annoying  disturbance  in  the  left  ear.  The 
utterances  heard  are  always  profane  or  otherwise  bad,  and  on  "giving 
himself  up  "  to  the  delusion,  he  believes  himself  to  be  the  subject  of 
abusive  language.  When  he  himself  is  not  directly  the  subject  of  in- 
vectives, he  is  still  cognizant  of  a  colloquy  between  two  individuals 
on  some  other  topic.  He  cannot  escape  from  these  unbidden  de- 
famers  at  will,  but  sometimes  the  noises  in  his  head  are  less  pro- 
nounced, and  then  the  hallucinatious  are  also  less  marked.  At  such 
times  he  is  less  worried,  and  feels  as  though  he  "could  control  him- 
self" and  throw  the  delusions  off.     There  are  times,  however,  when 


AUKAL    PHENOMENA   AND    BRAIN    AFFECTIONS.  355 

the  voices  do  not  din  so  unceasingly  in  the  ear,  but  then  he  finds 
himself  annoyed  by  knocks  upon  his  door  and  steps  in  the  hall ;  these 
sometimes  arouse  him  up  out  of  a  semi-unconscious  state  with  a 
shock.  He  often  fancies  ''  a  party  in  the  house  is  playing  a  game  on 
him''  with  aa  electric  battery;  he  can  hear  it  "click,"  and  "it 
nearly  shakes  him  out  of  bed,  and  plays  on  his  head  like  a  hose." 
Then  he  is  annoyed  by  speaking  and  whistling  through  a  gas-pipe  or 
tube  coming  up  through  the  floor.  Sometimes  he  "  feels  a  kind  of 
dizziness  through  the  head."  He  has  been  to  a  police  station  about 
this  trouble.  He  says  the  "  voices  "  always  remain  outside  the  door. 
One  of  the  "voices"  is  a  heavy  "bass"  voice,  the  other  is  "high 
and  squeaky,"  and  may  be  a  woman's  or  a  boy's  ;  they  are  compara- 
tively as  a  "tin  whistle  to  a  cornet." 

The  patient's  attention  having  dwelt  on  this  matter,  the  phenom- 
ena have  greatly  increased  in  importance  ;  he  now  hears  the  bass 
voice  in  the  left  ear,  the  tenor  in  the  right  one,  whereas  at  first 
every  sound  seemed  to  enter  the  left  ear. 

There  is  no  history  of  any  previous  disease  of  the  ear.  Syphilis  is 
denied.  He  has  chronic  catarrhal  Inflammation  of  the  upper  air- 
tract  (hypertrophic).  The  drum-heads  are  lustreless  and  somewhat 
atrophied;  the  anterior  segment  of  both  is  dry  and  wrinkled.  The 
left  membrana  flaccida  is  hyperaemic,  and  has  a  fleshy  appearance. 
There  are  other  evidences  of  loss  of  tension  in  the  transmitting 
mechanism — thus  there  is  general  relaxation  of  the  exterior  parts  of 
the  ear,  the  skin  in  front  of  the  tragus  on  both  sides  is  notably  re- 
laxed, as  is  shown  by  several  wrinkles.  Inflation  of  the  drum  with 
the  air-bag  has  caused  the  tinnitus  to  cease  for  ten  or  fifteen  minutes; 
closure  of  the  meatus  seems  to  muffle  the  sounds  heard.  His  own 
voice  never  sounds  autophonously.  Hearing  is  defective,  ordinary 
voice  only  being  heard  distinctly  at  a  distance  of  ten  feet. 

The  patient  was  advised  to  find  occupation,  and  when  not  at  work  to 
seek  relief  by  keeping  in  the  noise  on  the  streets,  etc.,  as  much  as 
possible.  He  found,  however,  that  the  noise  of  trucks,  horse-cars, 
and  other  heavy  vehicles  made  him  worse,  since  the  loudness  of  the 
voices  heard  was  also  increased.  He  noticed  that  he  was  much  better 
after  remaining  a  few  days  in  the  country. 

A  prominent  neurologist,  who  saw  the  patient,  considered  that  he 
had  both  insane  delusions  and  hallucinations,  due  to  some  form  of 
chronic  cerebral  disease  arising  from  alcoholism,  and  that  he  was 
liable  to  become  a  dangerous  lunatic.  He  found  the  tongue  to 
point  slightly  to  one  side,  and  the  pupils  to  be  unequal.  It  was 
thought  that  the  ophthalmoscope  might  throw  more  light  on  the 
case  than  could  be  gained  from  rational  symptoms,  and  an  examina- 
tion was  made.  Although  nothing  decisive  was  found  in  the  fundus, 
yet  the  vessels  of  the  left  eye  had  a  suspicious  look,  the  veins  being 
very  large  in  some  places  and  considerably  tortuous  ;  these  conditions 
might  suggest  commencing  trouble  from  tumor  of  the  brain  or  gum- 
mata. 

Interest  attaches  to  this  case,  not  from  disturbance  of  audition 
from  central  causation,  but  on  account  of  the  effect  of  the  tinnitus 


356  AURAL    PHENOMENA   AND    BRAIN    AFFECTIONS. 

aurium  upon  a  mind  already  predisposed  to  insane  hallucinations. 
At  first  the  hallucinations  were  notably  unilateral,  seemingly  for  the 
reason  of  greater  defectiveness  in  the  left  ear.  Subsequently,  how- 
ever, his  attention  was  frequently  directed  to  the  probable  bilateral 
source  of  the  voices,  and  then  it  was  that  he  began  to  fancy  the 
sounds  entered  both  ears. 

In  this  patient  the  ear  disease  was  well  marked  ;  and  it  would  seem 
that,  since  the  drum-head  may  present  recognizable  changes  in  many 
instances,  perhaps  in  a  very  considerable  number  of  mentally  insane 
persons  a  knowledge  of  the  condition  of  these  parts  might  be  availa- 
ble in  forming  a  diagnosis  of  the  case,  as  well  as  aiding  in  the  treat- 
ment. 

[The  patient  was  seen  during  the  autumn  of  1887,  when  he  ex- 
pressed himself  as  having  recovered.] 

The  two  following  cases  show  the  effect  of  aural  disturbances  on 
musical  persons. 

Case  7. — During  1877,  a  gentleman,  67  years  of  age,  extra- 
vagantly fond  of  music,  and  himself  once  a  performer  on  the  flute, 
became  subject  to  these  experiences  after  frequent  attacks  of  severe 
head  colds,  accompanied  by  very  considerable  deafness,  due,  in  great 
measure,  he  thought,  to  living  much  of  the  time  in  overheated  in- 
door air.  He  was  at  this  time  subject  to  much  worry  and  anxiety 
about  business  matters.  After  experiencing  annoying  roaring  in  the 
head  for  some  six  years,  the  noise  resembling  at  times  the  sound  pro- 
duced by  a  waterfall,  the  deafness  rapidly  increased  in  the  left  ear, 
and  for  two  months  before  consulting  the  author  about  this  trouble  he 
had  suffered  much  from  giddiness  and  unsteadiness  of  gait.  The 
vertiginous  symptoms  were  at  times  very  severe;  on  more  than  one 
occasion,  when  at  the  worst,  he  fell  prostrate  on  the  sidewalk,  and 
once  the  attack  was  grave  enough  to  require  the  assistance  of  a 
passing  friend  who  took  him  home.  At  this  time,  his  fretting  in- 
creased, and  various  hallucinations  were  experienced;  for  example, 
his  head  seemed  full  of  the  roar  of  street  noises,  and  it  only  required 
the  sight  of  a  church  to  set  going  the  sounds  of  an  organ  in  the  affected 
ear  (left).  Very  often,  when  walking  along  the  streets,  or  when  in 
his  own  house,  he  found  himself  listening  to  the  apparent  tones  of 
an  organ;  no  other  instrument,  in  fact,  seemed  to  enter  into  his 
thoughts,  or  to  be  so  well  suited  to  disturb  his  ear;  even  the  music  of 
the  organ  was  composed  of  disconnected  chords,  and  this  disjointed 
and  incomplete  perception  annoyed  him  greatly.  The  most  dis- 
tressing experience,  however,  was  the  apparent  singing  of  canary  birds 
in  the  air,  these  having  no  existence,  although  he  could  have  sworn 
that  these  songsters  were  singing  near  by.  It  is  notable  that  the 
canary's  song  was  anything  but  agreeable  to  the  patient,  since  its 
natural  quality  does  not  consist  in  a  continuous  flow  of  melody,  but 
is  composed  of  "  shakes,"  such  as  might  be  made  with  an  instrument 


AURAL   PHENOMENA    AND    BRAIN    AFFECTIONS.  35T 

of  high  pitch  like  the  oboe.  The  musical  fancies  were  not  all  dis- 
agreeable, but  the  autophonia,  hallucinations,  and  financial  difficul- 
ties all  together  brought  about  a  nervous  state  which  for  a  time  made 
life  miserable  ii\  the  extreme.  On  one  occasion,  he  was  induced  to 
attend  a  concert,  in  the  hope  of  diverting  his  thoughts  into  a  more 
agreeable  channel,  but  the  music  seemed  discordant  and  was  rather 
confusing  than  soothing  in  its  effects;  it  finally  became  so  painful  as 
to  be  unendurable,  and  he  fled  from  the  room.  Of  late  this  patient 
has  very  much  improved,  and  although  he  still  has  much  tinnitus, 
and  remains  inconveniently  deaf  to  conversation,  hallucinations  no 
longer  exist,  and  the  capacity  for  musical  enjoyment  has  returned. 

Case  8. — Patient  is  a  German,  72  years  of  age,  and  has  been  an 
accomplished  teacher  of  music.  He  is  now  in  his  senescence,  and 
experiences  hallucinations  in  a  remarkable  degree.  When  first  seen, 
in  February,  1884,  he  gave  the  following  history: 

General  health  always  fair,  but  has  suffered  from  nasal  catarrh, 
during  exacerbations  of  which  hearing  for  ordinary  sounds  was  di- 
minished, and  autophonia  was  present  and  inability  to  distinguish  the 
notes  of  a  piano.  During  the  past  five  years,  he  has  had,  at  infrequent 
intervals,  attacks  of  otalgia  in  both  ears.  The  deafness  has  increased 
during  the  past  year,  obliging  the  patient  to  give  up  teaching,  he 
being  no  longer  able  to  detect  the  exact  key  of  a  note;  "  it  would 
sound  either  sharp  or  flat."  Both  drum- heads  give  evidences  of 
long-standing  catarrh.  Autophonia  is  well  marked,  tinnitus  con- 
stant, and  he  hears  only  shouting  voice,  in  both  ears,  at  ten  feet  dis- 
tance. It  is  found  that  he  can  distinguish  harmony  on  the  piano 
from  discord  when  these  different  expressions  are  intensified  so  as  to 
be  well  heard;  but  he  fails  to  detect  the  difference  between  a  full  har- 
monious chord  and  one  which  is  rendered  slightly  inharmonious  by 
the  introduction  of  one  or  more  discordant  notes.  In  respect  to  the 
patient's  hallucinations,  it  may  be  said  that  they  have  been  experienced, 
in  some  degree,  for  four  years,  but  during  the  past  year  the  musical 
experiences  were  especially  marked.  He  states  that,  after  composing 
a  certain  air,  he  then  proceeds  to  play  it  on  the  piano,  finishing  the 
first  two  or  three  bars,  and  then  stopping;  the  rest  of  the  piece  is  then 
immediately  completed  by  a  full  orchestra,  apparently,  and  played 
through  correctly.  When  alone  in  his  room,  familiar  orchestral  airs 
are  heard  at  times;  if  any  part  is  rendered  incorrectly,  it  occurs  to 
him  at  the  moment  ''that  was  played  wrong,"  when  immediately  the 
piece  is  repeated,  this  time  correctly.  Thinkingof  an  air  will  at  times 
suflRce  to  produce  either  an  instrumental  or  vocal  rendering  in  the 
ears.  He  fancies  that  his  daughter,  who  has  been  dead  for  a  year, 
sings  familiar  airs  to  him.  Ordinary  street  sounds,  as  the  rumbling 
of  trucks,  stages,  and  horse-cars,  sound  musical,  like  the  intonations 
and  notes  of  a  full  orchestra.  There  are  intervals  after  performing 
the  Valsalvan  experiment,  or  swallowing,  when  the  street  sounds 
above  mentioned  are  entirely  stopped.  The  patient  makes  the  sin- 
gular mistake  of  believing  the  tinnitus,  etc.,  to  be  subjective  or 
imaginary,  whilst  the  musical  tones  and  sounds  made  by  fancied  visi- 
tors from  another  world  he  believes  to  be  actual. 


CHAPTEE    XYIL 

THE    OPERATION    OF    EXCISION    OF    THE    DRUM- 
,  HEAD    AND    OSSICLES. 

The  experience  of  the  past  decade  in  aural  surgery  has  led  to  the 
fulfilment  of  the  hopes  of  Sir  Astley  Cooper  and  other  surgeons  of  the 
past,  in  respect  to  the  relief  of  deafness  by  means  of  an  operation 
which  should  admit  sound  to  the  fenestrse  set  in  the  wall  between  tym- 
panum and  labyrinth,  by  establishing  a  permanent  opening  in  the 
drum-head.  Otologists  are  thus  enabled  to  avail  themselves  of  the 
more  accurate  anatomical  and  pathological  knowledge  developed  dur- 
ing the  past  twenty  years,  in  adopting  a  radical  plan  of  treatment  in 
cases  of  chronic  purulent  and  non-purulent  inflammation  of  the 
middle  ear. 

From  a  long  experience  in  the  treatment  of  aural  disease  the  writer 
felicitates  himself,  at  least,  in  escaping  from  the  ancient  routine,  al- 
most limited,  in  chronic  purulent  processes,  to  the  removal  of  polypi 
and  the  miscellaneous  introduction  of  caustic  and  astringent  medica- 
ments into  the  external  auditory  canal,  thereby  temporizing  with 
what  often  proved  to  be  irremediable  purulency. 

Before  proceeding  further,  it  will  be  well  to  devote  some  space  to 
the  history  of  operations  involving  the  extirpation  of  portions  or  the 
whole  of  the  transmitting  mechanism  for  the  relief  of  otorrhoea  and 
the  improvement  of  hearing,  up  to  the  present  date.  Partial  excision 
of  the  membrana  tympani  to  improve  the  hearing  was  attempted 
many  years  since  and  in  various  ways,  such  as  those  recommended 
by  Himly,  Fabrizi,  Brunner,  Deleau,  Bonnafont  (1860).  The  chief 
diflBculty,  however,  lay  in  the  attempts  at  preserving  the  opening  in 
the  drum-head  thus  made.  To  accomplish  this,  Wreden  proposed 
excising  the  manubrium  mallei.  The  results  of  this  procedure  were 
in  no  respect  more  satisfactory  than  before.  No  greater  success  fol- 
lowed the  attempts  made  by  the  application  of  various  acids,  the 
galvano-cautery,  etc. 


EXCISION    OF    THE   DRUM-HEAD   AND    038ICLE8.  359 

In  Schwartze's  work  on  the  surgical  diseases  of  the  ear,'  the  author 
states  that,  since  great  damage  to  the  hearing  power  does  not  neces- 
sarily follow  loss  of  the  malleus  and  incus  in  cases  of  chronic  purulent 
processes,  the  idea  suggests  itself  to  remove  these  "  otherwise  incur- 
able obstructions  to  the  transmitting  mechanism  of  the  drum,  and 
which  lie  externally  to  the  stapes,  arising  mostly  in  fixation  of  the 
malleus  and  incus,  by  excision  of  these  ossicles."  (Italics  the  present 
writer's.) 

Schwartze's  first  attempts  at  excision  of  the  drum-head  and  ex- 
traction of  the  entire  malleus  in  cases  of  sclerosis  were  made  in  1873.* 
The  results,  though  at  first  successful,  were  but  temporary,  owing  to 
the  rapid  regeneration  of  the  excised  drum-head,  which  invariably 
followed. 

The  labors  of  J.  Kessel,  of  Graz,  in  this  direction  are  meritorious 
and  should  be  alluded  to  at  length.  Aside  from  his  experiments 
made  to  improve  hearing  by  division  of  the  adhesions,  etc,  sur- 
rounding the  stapes,"  Kessel  reported  in  1878*  a  case  of  removal  of 
the  drum-head,  malleus,  and  incus  in  a  patient  suffering  from  chronic 
catarrh  of  the  middle  ear  with  closure  of  the  Eustachian  tube,  as 
follows: 

Male  patient,  aged  24  years.  Closure  of  the  Eustachian  tube  from 
catarrh  of  naso-pharynx.  Hearing  in  right  ear  for  conversation  at 
fifty  centimetres;  in  left  ear  for  conversation  at  ten  centimetres. 
Tinnitus  very  great  and  mostly  in  the  left  ear. 

Eight  drum-head  retracted;  left  inverted. 

Operation:  Left  ear.  Chloroform  narcosis.  Incision  of  drum- 
head with  lance-shaped  knife  about  its  groove  at  the  Kivinian  seg- 
ment and  detached  around  its  periphery.  Tenotomy  of  tensor  tympani 
and  extraction  of  malleus.  Drum  filled  with  sticky,  clear  mucus. 
The  incus  and  stapes  had  become  displaced  into  the  upper  part  of 
tympanum.  Incus  easily  extracted.  Stapes  left  in  position.  Hemor- 
rhage slight.  Patient  heard  voice  immediately  after  the  operation 
and  tinnitus  was  less.  Inflammation  of  the  integument  of  the  ex- 
ternal auditory  canal  occurring  during  the  following  few  days,  caused 
decrease  in  the  hearing  power.  On  the  sixth  day  hearing  began  to 
improve  again,  and  in  a  month's  time  patient  could  hear  whispered 
words  at  ten  metres  distance  and  the  rain  striking  against  the 
■window  panes.  Tinnitus  was  slight,  as  was  also  the  secretion  from 
the  drum.     From  this  time  on,  however,  relapse  began;  his  hearing 

'  Die  chirurgischen  Krankheiten  des  Ohres.     Dr.    Hermann  Schwartze. 
Stuttgart,  1885,  page  279. 
^Op.  cit,  p.  380. 

8  Archiv  fiir  Ohrenheilkunde,  Vol.  XI.,  1876,  p.  199. 
-*  Archiv  fur  Ohrenheilkunde,  Vol.  XIII.,  1878,  p.  69. 


360  EXCISION   OF   THE    DRUM-HEAD   AJJD   OSSICLES. 

power  diminished.  In  two  months'  time  a  thin  newly  formed  mem- 
brane closed  the  opening  into  the  drum,  being  adherent  to  the  pro- 
montory. This  was  detached,  the  posterior  portion  of  the  bony  and 
cartilaginous  rings  excised,  in  the  hopes  of  preventing  regeneration 
of  the  entire  membrane,  and  maintaining  an  opening.  Regeneration 
of  the  membrane.  Two  weeks  later  galvano-cautery  applied  to  the 
cartilaginous  ring,  by  which  a  small  opening  was  maintained  for  two 
or  three  weeks.  The  membrane,  however,  closed  again,  becoming 
fast  adherent  to  the  promontory.  Tinnitus  slight.  Patient  heard 
voice  at  ten  metres  distance,  but  not  as  well  as  during  the  first  month 
following  the  operation. 

Kessel  states  that  the  result  in  five  other  cases  was  just  the  same  as 
in  the  above,  the  incipient  success  being  regularly  destroyed  by 
regeneration  of  the  drum-head.  The  possibility,  however,  of  main- 
taining an  opening  by  the  cautery  induced  him  to  continue  the 
operation.  He  then  proposed  chiselling  off  the  bony  sulcus  and  the 
tendinous  ring  at  the  posterior  segment,  which  he  thought  might 
remove  the  diflBculty.  Kessel  recommended  even  the  extraction  of 
the  stapes  for  certain  conditions,  and  went  so  far  as  to  do  this  in 
one  case,  his  experiments  on  dogs  and  pigeons  in  1871  having  proved 
that  removal  of  the  stapes  does  not  cause  either  vertigo  or  lesions 
in  co-ordination,  and  that  the  deafness,  present  at  first,  disappears 
as  soon  as  the  oval  window  is  closed  by  a  newly  formed  membrane. 

A  paper  read  by  Kessel  in  the  tenth  Monthly  Meeting  of  the  Society 
of  Physicians  in  Steiermark,  27th  October,  l.s79,'  "  On  the  Excision 
of  the  Drum-head  and  '  Mobilization  '  of  the  Stapes,"  contains  further 
exhibition  and  exposition  of  results  in  a  few  new  cases.  He  says 
that  excision  of  the  drum-head  and  "mobilization"  of  the  stapes 
is  indicated  where  the  middle  ear  apparatus  is  immovable;  in  cases 
of  closure  of  the  Eustachian  tube,  total  calcification  of  the  drum-head 
with  deafness,  caries  of  the  ossicles,  ankylosis  of  the  stapes,  and  dis- 
tressing tinnitus,  and  cholesteatoma  of  the  drum  and  the  mastoid, 
when  they  cannot  be  removed  in  the  usual  manner. 

Kessel's  method  of  operating  is  as  follows: 

Narcosis.  Drum-head,  if  present,  excised  around  its  periphery, 
including  also  in  the  posterior  segment  the  tendinous  ring,  to  prevent 
regeneration  of  tissues  at  that  point.  Tenotomy  of  tensor  tympani. 
The  loop  of  a  snare  now  passed  around  the  malleus  handle  and  it,  to- 
gether with  the  detached  drum-head,  removed.  If  the  incus  be  found 
healthy  and  the  long  process  movable,  it  may  be  left  in  the  drum. 
Kessel  had  operated  in  sixteen  cases  with  no  bad  results.  He  gives 
the  histories  of  the  following  three  cases: 

'  Archiv  fur  Ohrenheilkunde.  Vol.  XVI.,  1880,  page  196. 


EXCISION   OF   THE    DRUM-HEAD    AND   OSSICLES.  361 

Male,  39  years  of  age.  Fixation  of  ossicles.  Complete  deafness 
for  voice.  Distressing  tinnitus.  Some  relief  for  the  tinnitus  afforded 
by  the  operation.  Incudo-stapedial  joint  dislocated  backward.  Otor- 
rhoea  for  a  short  time  afterwards.  Tinnitus  ceased  in  six  months. 
Gradual  improvement  in  hearing.     Parts  dry. 

Female,  aged  23  years.  Otorrhoea  since  childhood.  Eight  drum- 
head gone;  malleus  retracted  against  promontory.  No  hearing  for 
voice.  Much  tinnitus.  Excision  of  remains  of  drum-head,  malleus 
and  incus.  Discliarge  ceased  in  eight  days.  Tinnitus  ceased  per- 
manently after  the  operation.  Whispered  words  heard  close  to  the 
ear;  ordinary  voice  at  one  metre  distance. 

Male,  25  years  old.  Deafness  and  tinnitus  since  childhood;  worse 
in  left  ear.  Only  vowels  heard  in  left  ear.  Loss  of  memory;  vertigo. 
Left  drum-head  opaque,  thickened.  Eustachian  tube  free.  Excision 
of  left  drum-head  and  malleus  handle  (the  latter  broke  off  in  the 
operation).  The  following  day  the  voice  was  heard  close  by  the  ear. 
Less  tinnitus.  A  discharge  set  in  on  the  third  day,  and  lasted  for 
three  weeks,  during  which  the  head  of  the  hammer  was  probably 
cast  out.  Kegeneration  of  the  drum-head  excepting  in  the  posterior 
segment,  where  the  ring  was  excised.  Adherent  to  promontory. 
Tinnitus  and  other  symptoms  disappeared  in  six  weeks.  Conversation 
understood  at  several  metres  distance. 

In  an  article  '  published  by  August  Lucae  in  1881,  that  author 
mentions  a  case  of  a  female  patient,  suffering  from  the  results  of  chronic 
catarrhal  inflammation  of  the  middle  ear,  upon  whom  he  performed 
excision  of  the  entire  drum-head  and  malleus  (left  ear).  The  results 
of  this  procedure  were  entirely  satisfactory  to  the  patient  who  in- 
sisted upon  a  like  operation  being  performed  in  the  right  ear.  A 
continual  high  degree  of  sensitiveness  to  loud  noises  waS  noticed  in 
both  ears  for  some  time  after  the  operation.  A  large  defect  in  the 
regenerated  membrane  remained.  There  was  some  reactive  inflam- 
mation of  the  parts  following  the  operation  and  some  vertigo,  all 
of  which  disappeared  shortly,  however.  Hearing  greatly  improved, 
especially  for  musical  sounds. 

In  a  paper"  read  before  the  Section  of  Otology  at  the  International 
Medical  Congress,  held  in  London,  1881,  Lucae  mentions  the  fact 
that  he  has  performed  excision  of  the  drum-head  with  the  malleus  in 
twenty-five  cases,  in  none  of  whom  had  any  deterioration  of  the  hear- 
ing power  taken  place;  in  some,  on  the  contrary,  a  very  considerable 

'  Ueber  optischen  Schwindel  bei  Druckerhohung  im  Ohr.  Archiv  fiir 
Ohrenheilkunde,  Vol.  XVII.,  1881. 

^  Zur  physikalischen  differentiellen  Diagnostik  zwischen  Erkrankung  de& 
schallleitendea  Apparates  und  Nerventaubheit.  Mit  Demonstrationen.  Archiv 
fur  Ohrenheilkunde,  Vol.  XIX.,  1883. 


362  EXCISION   OF   THE    DRUM-HEAD   AND    OSSICLES. 

improvement  in  this.  In  1883  the  number  of  Lucae's  operations  ex- 
ceeded forty.' 

Prof.  Schwartze,  in  reviewing  the  therapeutical  value  of  this  opera- 
tion, says  : "  ''total  excision  of  the  drum-head  with  the  malleus  may 
be  follotved  by  permanent  improvement  of  the  hearing  power  in  cases 
of  total  calcification  of  the  drum-head,  and  also  in  cases  of  fixation 
of  the  malleus  due  to  ankylosis  of  the  malleo-incudal  articulation  or 
adhesion  of  the  malleus  head  to  the  upper  wall  of  the  tympanum, 
when  no  farther  obstruction  to  the  transmission  of  sound  to  the  audi- 
tory nerve  is  present  in  the  windows  of  the  labyrinth,  etc."  He  rec- 
ommends KesseFs  method  of  removing  the  posterior  portion  of  the 
tendinous  ring,  eventually  also  the  chiselling  off  of  the  upper  portion 
of  the  sulcus  tympani,  to  prevent  regeneration  of  the  drum-head. 
"  Nevertheless,"  he  further  states,  "  even  when  the  excised  drum- 
head is  replaced  by  a  membrane,  closing  the  way  to  the  labyrinth 
windows,  a  part  of  the  improvement  resulting  from  the  operation, 
especially  the  cessation  of  the  distressing  tinnitus,  may  be  permanent.'* 
He  recommends  total  excision  of  the  drum-head  and  hammer  in  cases 
of  incurable  chronic  purulent  inflammation  of  the  middle  ear,  as  one 
without  danger,  and  frequently  attended  by  success.  Even  when  it 
afterwards  becomes  apparent  that,  besides  the  caries  of  the  malleus, 
other  parts  of  the  middle  ear  tract  are  in  a  carious  condition,  excision 
is  beneficial,  inasmuch  as  by  this  means  better  escape  for  the  secre- 
tions is  afforded  and  the  cavity  of  the  drum  made  more  accessible  to 
treatment.  Schwartze  states  that  the  general  result  of  his  own  op- 
erative attempts  incline  him  to  the  opinion  that  excision  is  followed 
by  better  results  in  cases  of  chronic  purulency  of  the  middle  ear,  or 
its  residues,  than  in  cases  of  sclerosis. 

Schwartze  gives  the  following  as  indications  for  the  operation: 
Excision  of  the  drum-head  and  ossicles  is  indicated  in  cases  of  chronic 
purulent  inflammation  of  the  middle  ear  with  caries  of  the  ossicles; 
furthermore,  in  cases  of  cholesteatoma  of  the  tympanum.  He  says:  ' 
*' non-cessation  of  the  purulent  discharge  immediately  after  the  ex- 
cision would  point  to  the  existence  of  some  other  carious  spot  either 
in  the  tympanum  or  in  the  air-cells  of  the  mastoid  process.  In  the 
first  instance,  excision  of  the  drum-head  permits  at  any  rate  of  a  more 
careful  diagnosis  by  means  of  the  probe  and  the  possibility  of  direct 
irrigation  and  cauterization  of  the  diseased  portion  of  bone  ;  on  the 
other  hand,  opening  of  the  mastoid  antrum,  as  a  subsequent  operation, 

'  Archiv  fur  Ohrenheilkunde,  Vol.  XIX.,  1883,  page  75  (see  foot-note), 
«  Op.  cit.,  page  285. 
*  Op.  cit.,  page  281. 


EXCISION   OF   THE   DKUM-HEAD    AND   OSSICLES.  363 

-would  have  to  be  considered.  By  means  of  the  latter  any  retention 
of  purulent  matter  and  caries  of  the  ear- chambers  over  the  auditory 
canal,  which  connect  with  those  of  the  mastoid  process,  would  be 
made  accessible  to  treatment." 

This  is  practically  what  Kessel  had  already  stated.  (See  p.  360.) 
Schwartze  considers  that  the  operation  is  indicated,  furthermore,  ia 
cases  of  "fixation  of  the  malleus  resulting  from  total  calcification 
of  the  drum-head  or  from  ankylosis  of  the  malleo-incudal  articula- 
tion." "Hearing  for  the  voice  must  be  present;  if  whispered 
words  are  easily  understood  close  to  the  ear,  there  is  little  probability 
of  improving  the  hearing  by  the  operation,"  In  such  cases  excision 
of  the  entire  drum-head  together  with  the  hammer  may,  according 
to  the  same  author,  permanently  remove  the  tinnitus  and  improve 
the  hearing  power  to  such  a  degree  that  whispered  words  can  be  heard 
in  the  neighborhood  of  the  ear. 

"  This  is  only  possible  when  no  calcification  or  other  obstructions 
to  the  transmission  of  sound  are  present  in  the  windows  of  the  laby- 
rinth." 

"  Excision  of  the  malleus,"  he  goes  on  to  say,  "  is  beyond  all  doubt 
of  value  in  cases  of  isolated  ankylosis  of  the  malleo-incudal  articula- 
tion without  co-existing  ankylosis  of  the  stapes."  The  incudo-stape- 
dial  articulation  should  be  divided,  in  order  to  avoid  damaging  the 
stapes,  when  removing  the  incus  and  malleus. 

"The  incus  may  remain  without  harm  in  the  tympanum,  if  it  does 
not  come  away  easily.  Since  diagnosis  of  isolated  ankylosis  of  the 
malleo-incudal  articulation  is  so  uncertain,  it  will  be  impossible  to 
rely  for  a  certainty  on  a  good  result  from  the  operation." 

Should  excision  of  the  drum-head  with  the  malleus  result  in  less 
being  heard  than  whispered  words  close  by  the  ear,  after  the  reactive 
inflammation  has  subsided,  obstructions  to  the  transmission  of  sound 
other  than  fixation  of  the  malleus  must  certainly  exist. 

The  operation  is  indicated,  furthermore,  we  are  told,  "in  cases  of 
closure  of  the  Eustachian  tube,  as  soon  as  it  is  shown  that  a  proba- 
tory incision  into  the  retracted  drum-head  results  in  a  considerable 
improvement  in  the  hearing  power,  with  simultaneous  return  of  the 
drum-head  to  its  plane." 

Schwartze's  method  of  operating  is  as  follows  : 

The  degree  of  sensitiveness  of  the  drum-head  is  first  tested  by  the 
probe,  and,  if  much  reduced,  as  in  cases  of  thickening,  etc.,  narcosis 
will  not  be  necessary.  The  head  of  the  patient  is  held  by  an  assistant, 
the  auricle  being  pulled  backwards  and  upwards.  A  deep  narcosis 
will,  however,  be  generally  found  necessary,  especially  in  very  nervous 


364:  EXCISION   OF   THE    DRUM-HEAD    AND   OSSICLES. 

patients.  If  the  drum-head  be  much  retracted,  it  will  be  well  to  use 
Politzer's  air-bag  to  inflate  the  drum.  The  drum-head  is  excised 
close  to  its  periphery,  together  with  a  portion  of  the  cartilaginous 
ring  in  the  posterior  segment.  Tenotomy  of  the  tensor  tympani  and 
division  of  the  incudo-stapedial  articulation  then  follow,  whereupon 
the  excised  drum-head  together  with  the  malleus  are  grasped  with 
the  snare  and  extracted.  The  operation  will  be  usually  followed  by 
inflammation  of  the  parts  and  otorrhoea,  beginning'  during  the  next 
twenty-four  to  thirty-six  hours,  and  lasting  for  a  week  or  even  for 
months. 

Schwartze  gives  the  histories  of  six  cases  operated  by  himself. 
Three  of  these  patients  were  suffering  from  chronic  purulent  inflam- 
mation of  the  middle  ear,  with  caries  of  the  malleus  head.  All  three 
were  males,  aged  respectively  36,  20,  and  19  years,  in  whom  the  dis- 
ease had  existed  for  a  long  time.  The  results  of  the  operation  in 
these  cases  were  satisfactory,  the  otorrhoea  ceasing  entirely  in  from 
six  weeks  to  fifteen  months'  time.  The  fourth  case  is  that  of  a  male 
patient,  45  years  of  age,  with  the  results  of  chronic  purulent  inflam- 
mation, fixation  of  the  malleus,  etc. 

The  distressing  tinnitus  was  permanently  and  completely  cured  by 
the  operation.  The  improvement  in  the  hearing  power,  however, 
which  existed  during  the  first  six  months  after  the  operation,  disap- 
peared. In  the  last  two  cases  the  operation  was  undertaken  for  the 
improvement  of  hearing  and  relief  of  tinnitus  ;  sclerosis  of  the  drum- 
head and  ankylosis  of  the  incudo-stapedial  joint  was  present  in  both 
patients.  In  one  of  them  the  cartilaginous  ring  was  not  excised. 
In  both  instances  regeneration  of  the  drum-head  followed.  The  tin- 
nitus was  almost  entirely  cured  in  the  one  case,  whilst  in  the  other 
no  improvement  in  the  subjective  symptoms  took  place.  In  neither 
was  the  operation  followed  by  any  improvement  of  hearing  worthy  of 
mention. 

As  has  been  already  mentioned  above,  Lucae  reported  in  1883  that 
the  number  of  cases  in  which  he  had  performed  this  operation  ex- 
ceeded forty.  In  1885  Lucae  published  a  full  report  *  of  his  work  in 
this  direction  up  to  that  date,  showing  a  total  number  of  fifty-three 
operations  performed  in  forty-seven  patients,  six  times  in  both  ears. 

In  all  of  these  cases  the  malleus  was  removed,  in  six  patients  the 
incus  also.  He  usually  operated  in  chloroform  narcosis  ;  in  five  cases, 
however,  without  any  narcosis.     Lucae  says  he  undertook  the  opera- 

'  Ueber  operative  Entfernung  des  Trommelfells  und  der  beiden  grosseren 
Gehdrknochelchen  bei  Sclerose  der  Paukenschleimhaut,  Archiv  fur  Ohren- 
heilkunde,  Vol.  XXII.,  1885. 


EXCISION    OF    THE    DRUM-HEAD    AND    08SICLE8.  365 

tion  at  first  only  in  those  persons  having  a  relatively  good  perception 
for  high  tones,  but  later  on  also  in  those  patients  where  this  was  re- 
duced or  indeed  quite  absent. 

Lucae's  method  of  operating  is  the  following  : 

By  means  of  a  lance-shaped  needle  a  puncture  is  made  in  front  of 
and  behind  the  short  process,  then  into  these  openings  a  sharp  probe- 
pointed  knife  is  introduced,  with  which  the  anterior  and  posterior 
halves  of  the  drum-head  are  divided  to  its  periphery,  the  two  sec- 
tions being  then  united  by  circular  cuts.  Tenotomy  of  the  tensor 
tympani  with  Schwartze's  tenotomy  knife  follows,  and  if  the  incudo- 
stapedial  articulation  is  visible,  he  divides  this  also.  To  remove  the 
malleus,  he  uses  an  instrument  resembling  a  small  lithotriptor,  with 
which  he  is  able  to  maintain  a  firm  grasp  on  the  ossicle.  In  a  few 
of  his  cases  he  chiselled  away  a  piece  of  the  cartilaginous  ring,  after 
Kessel's  method,  partly  in  order  to  extract  the  incus,  partly  to  expose 
the  incudo-stapedial  articulation.  The  latter  was  visible  in  only  the 
smaller  portion  of  his  cases.  Lucae  is  rather  inclined  to  doubt  the 
utility  of  Kessel's  ''mobilization,"  so  called,  of  the  stapes,  having 
tried  it  in  three  cases  apparently  without  any  result.  In  one  case  he 
says  he  broke  off  both  branches  of  the  stapes. 

Before  operating  he  irrigates  the  ear  with  antiseptic  fluids,  and 
after  the  operation  the  parts  are  irrigated  with  a  carbolized  solution, 
iodoform  being  insufflated  in  some  cases.  The  operation  lasted  but 
a  few  minutes.     Otitis  externa  followed  in  some  instances. 

The  results  of  Lucae's  operations  are  very  interesting  and  instructive. 
In  30  cases  the  adhesions,  thickening  of  the  tissues,  fixation  of  the 
ossicles,  etc.,  were  found  during  the  operation  to  be  very  considera- 
ble. Thirty-four  patients  had,  when  discharged,  a  larger  or  smaller 
opening  in  the  regenerated  drum-head  ;  in  17  the  new  drum-head 
closed  entirely,  and  in  2  cases  notes  regarding  this  point  were  not 
made.  Of  the  34  cases  where  an  opening  in  the  regenerated  drum- 
head remained,  10  had  been  under  observation  from  one  and  one-quar- 
ter years  to  five  years  ;  24  under  one  year's  time. 

In  9  cases  the  improvement  in  the  hearing  power  was  very  con- 
siderable ;  in  19  it  was  slight,  in  18  cases  there  was  no  improvement 
in  hearing,  and  in  7  cases  the  latter  became  worse  after  the  operation. 

In  the  38  cases  just  mentioned,  showing  more  or  less  improved 
tearing,  it  was  remarked  that  the  highest  tones  were  much  better 
heard  than  the  deeper  ones.  In  21  of  these  cases  an  opening  in  the 
newly  formed  drum-head  remained ;  in  6  entire  closure  took  place, 
and  in  1  case  no  notes  were  made  of  the  condition. 

In  8  cases  the  opening  remaining  in  the  regenerated  drum-head  was 


366  EXCISION    OF   THE    DKUM-HEAD   AND    OSSICLES. 

large  and  "  dry/'  One  of  these  cases  continued  under  Lucae*s  obser- 
yation  for  five  years.  This  case  has  been  previously  described  on 
page  361. 

Lucae  calls  attention  to  the  fact  that  the  opening  in  the  newly 
formed  drum-head  is  not  to  be  considered  altogether  as  the  chief  fac- 
tor in  the  improvement  in  hearing,  basing  his  remarks  on  the  fact 
that  of  the  9  cases  showing  very  considerable  improvement  in  hearing, 
in  6  the  opening  in  the  drum-head  remained,  whilst  in  the  3 
others  where  closure  took  place,  the  greatest  improvement  in  the 
hearing  power  was  observed. 

Eegarding  the  influence  of  the  operation  on  the  subjective  symp- 
toms, notes  are  only  given  in  19  cases.  In  these  the  tinnitus  ceased 
entirely  in  1,  in  7  it  decreased  in  intensity,  in  10  it  remained 
unchanged,  whilst  in  1  it  changed  to  a  disagreeable  ringing  noise. 

The  operation  in  Lucae's  hands  was  never  attended  by  any  untoward 
complications,  and,  like  Schwartze,  he  considers  that  none  of  the 
procedures  of  the  operation  are  in  any  way  hazardous. 

The  results  obtained  by  his  operations  were  not  so  satisfactory  to 
him  as  they  might  have  been  had  the  knowledge  of  the  subject  fur- 
nished him  better  indications  for  its  performance. 

Lucae  has  had  but  little  experience  in  operating  in  cases  of  chronic 
purulent  otitis  media  with  caries,  but  thinks  that  the  operation  in 
such  cases  promises  better  results. 

In  the  annual  report  of  the  University  Ear  Clinic  in  Halle  for  1885,^ 
Kretschmann  mentions  three  cases  of  exsection  of  the  malleus  for 
caries.  The  first  patient  was  a  male,  44  years  of  age,  suffering  from 
chronic  purulent  otitis  media.  There  was  caries  of  the  malleus,  a 
perforation  of  the  membrana  flaccida,  and  also  one  of  the  membrana 
vibrans  just  below  the  umbo.  Tinnitus,  vertigo,  and  deafness  were 
prominent  subjective  symptoms.  The  entire  drum-head  and  the 
malleus  were  excised  without  anaesthesia.  The  subjective  symptoms 
mentioned  subsided  after  the  operation.  The  fpatient  passed  from 
under  observation  in  two  weeks. 

The  other  two  cases  were  girls,  16  years  of  age.  In  both  the 
drum-head  was  entirely  destroyed,  and  the  malleus  occupied  a 
horizontal  position.  The  discharge  in  these  cases  was  very  slight.  In 
the  one  case  excision  was  extremely  difficult  and  was  followed  by  no 
result.     In  the  other  the  operation  was  incompletely  carried  out. 

'  Bericht  fiber  die  Thatigkeit  der  koniglichen  Universitats  Ohrenklinik  zu 
Halle  im  Jahre  1885,  von  Dr.  F.  Kretschmann,  Assistenzarzt.  Archiv  ffir 
OhrenheUkunde,  Vol.  XXIII.,  p.  234. 


EXCISION   OF    THE    DRUM-HEAD   AND   OSSICLES.  367 

In  a  later  article  '  Kretschmann  has,  furthermore.reported  six  cases 
of  excision  of  the  drum-head  and  ossicles  for  the  relief  of  the  disa- 
greeable subjective  phenomena  accompanying  chronic  purulent  in- 
flammation, especially  of  the  tympanic  attic  with  perforation  of  the 
membrana  flaccida  over  the  short  process  of  the  hammer.  The  results 
of  the  operation  were  very  satisfactory  in  every  instance,  the  foulness 
of  the  more  or  less  pent-up  secretions,  the  headaches,  vertigo,  tinnitus 
aurium,  etc.,  being  entirely  relieved.  In  one  case  the  malleus  was 
not  found  and  the  incus  was  apparently  not  removed  in  all  instances. 
For  bringing  this  latter  bonelet  into  view,  Kretschmann  employs  a 
small  instrument  with  a  hook-shaped  end,  on  the  point  of  which  is  a 
small  knob. 

Stacke"  (Erfurt)  recently  reported  ten  cases  of  removal  of  the 
malleus  for  chronic  purulency  of  the  middle  ear,  or  its  residues,  and 
also  in  cases  of  chronic  catarrh  of  the  drum,  for  the  relief  of  deafness, 
tinnitus,  etc.  All  these  cases  show  improvement  in  the  hearing 
power  (in  some  to  a  remarkable  degree),  or  relief  from  distressing  sub- 
jective phenomena  (headaches,  tinnitus,  etc.).  His  first  patient  was 
operated  in  June,  1885.  Six  of  his  cases  were  males  (one  had  both  ears 
operated),  three  were  females.  The  method  of  operating  employed  by 
this  author  resembles  closely  that  of  Schwartze,  and  he  considers  the 
use  of  antiseptic  irrigations  and  dressings  advisable. 

In  a  paper''  on  aural  vertigo,  read  before  the  Medical  Society  of  the 
State  of  Pennsylvania,  June  7th,  1888,  Dr.  Charles  H.  Burnett,  of 
Philadelphia,  reported  a  case  where  he  performed  excision  of  the 
drum-head,  malleus,  and  incus,  relieving  the  patient  entirely  from  all 
of  the  very  distressing  vertiginous  symptoms  that  had  long  existed. 

The  present  writer  has  long  known  that,  where  the  drum-head, 
malleus,  incus,  and  the  stapes,  excepting  perhaps  its  base,  have  been 
destroyed  by  suppurative  action,  followed  by  spontaneous  cure, 
and  leaving  the  entire  tympanic  cavity  covered  with  a  non-secreting 
membrane,  v«ry  good  hearing  may  remain.  Some  years  ago,  without 
knowledge  of  the  work  done  in  this  direction  abroad,  it  occurred  to 
him  that,  were  the  struct«res,  sometimes  found  remaining  in  the 
tympanum  in  a  hopelessly  diseased  condition,  removed  by  an  opera- 

'  Fisteloff nungen  am  oberen  Pole  des  Trommelf  ells  uber  dem  Processus  brevis 
des  Hammers,  deren  Pathogenese  und  Therapie.  Archiv  fur  Ohirenheilkunde, 
Vol.  XXV.,  p.  165. 

*  Archiv  fur  Ohrenheilkunde,  Vol.  XXVI,,  p.  115.  See  also  Abstract  ot 
above  by  Dr.  Chas.  H.  Burnett,  American  Journal  of  the  Medical  Sciences, 
Vol.  XCVI.,  No.  1,  July,  1888. 

»  Medical  News,  July  14th,  1888. 


368  EXCISION    OF   THE  DEUM-HEAD    AND    OSSICLES. 

tion,  otherwise  irremediable  cases  of  otorrhcea  might  speedily  be 
cured. 

In  considering  the  indications  for  the  operation  of  excision  in 
chronic  suppuration  of  the  middle  ear,  the  fact  presents  itself  that, 
where  the  drum  is  encumbered  with  objects,  now  useless  and  diseased, 
but  which  once  composed  the  transmitting  mechanism,  it  is  also  often 
a  reservoir  for  purulent  secretions;  in  other  words,  the  drum  has  lost 
its  normal  functions  and  has  become  a  source  of  infection  for  the  sys- 
tem. By  excision,  more  or  less  obstruction  to  hearing  is  removed, 
and  the  septic  influences  are  eradicated. 

Where  the  membrana  vibrans  has  lost,  say  one-half  of  its  substance, 
either  in  large  perforations  or  peripheral  defects,  and  great  deafness 
exists,  though  purulency  be  absent,  an  operation  promises  to  improve 
hearing  and  prevent  "gatherings"  in  the  ear.  Where,  as  a  result  of 
purulency,  there  are  adhesive  bands  or  ankylosis,  causing  great  inter- 
ference with  the  passage  of  sound,  the  operation  is  also  indicated  even 
when  the  drum-head  remains.  Of  course,  in  both  of  the  conditions 
just  mentioned,  where  hearing  in  one  ear  remains  good,  the  opera- 
tion would  only  be  advisable  for  the  relief  of  noises  in  the  ear;  indeed, 
it  may  here  be  stated  that  subjective  phenomena  alone,  in  some  in- 
stances, are  so  distressing  that  the  operation  for  their  relief  seems 
justifiable  even  where  good  hearing  exists. 

In  studying  a  large  number  of  cases  where  destructive  inflamma- 
tion has  left  only  a  small  portion  of  the  conductive  mechanism,  no 
longer  serving  to  aid  in  the  transmission  of  sound,  it  is  often  found 
that  this  condition  not  only  obstructs  the  entrance  of  sound,  but  the 
exit  of  secretions  as  well.  Thus,  where  the  membrana  flaccida  and  a 
portion  of  the  ossicular  chain  only  remain,  the  former  often  becomes 
thickened,  its  free  edge  inverted,  and  forming,  with  the  foldings  of 
the  altered  mucous  membrane,  a  pouch  below  the  tympanic  attic 
for  the  retention  of  putrescent  matters  which  escape  slowly;  in  some 
instances,  by  overflowing  the  pouch,  in  others,  through  fistulous 
openings  in  its  outer  wall,  or  via  the  Eustachian  tube.  In  acute 
exacerbations  from  head  catarrh,  the  means  of  escape  for  fluids  be- 
come closed  and  hence  the  periodical  "gatherings"  which  are  a 
source  of  so  much  distress.  Where  granulation  tissue  or  polypoid 
growths  are  present  in  the  attic  or  antrum,  drainage  is  still  further 
interfered  with.  The  irritation,  both  local  and  reflected  to  other 
regions,  is  almost  indefinitely  continued  under  the  ordinary  treat- 
ment in  many  of  these  cases. 

The  author's  first  operation  was  made  early  in  1886.  This  case 
(Case  I.  in  the  accompanying  table),  with  others,  was  presented  in  a 


EXCISION    OF    THR    DRUM-HEAD    AND   OSSICLES. 


369 


paper  read  by  him  at  the  nineteenth  annual  meeting  of  the  American 
Otological  Society  in  July  of  the  same  year.' 

The  brilliant  ilhimination  afforded  by  a  six-candle  power  incan- 
descent electric  lantern  ^  is  almost  a  necessity  for  the  successful  per- 
formance of  this  operation;  besides,  it  affords  protection  from  the 
danger  of  an  explosion  of  the  ether  used  in  the  narcosis. 

The  lantern,  and  band  by  means  of  which  it  is  attached  to  the  head 
when  used  in  this  operation,  are  shown  in  Fig.  53. 

The  patient  should  be  placed  on  a  restricted  diet  for  some  weeks 
previous  to  the  operation;  meat  and  stimulants  should  be  forbidden, 


Fig.  53.— The  body  of  the  lantern  (outside  diamster  l?a  inch  ,  length  1^  inch.),  is  made  of  vul- 
canized fibre,  a  non-couducting  and  heat-resisting  material,  and  completely  incloses  the  six- 
candle  ix)wer  incandescent  lamp.  By  this  means  the  unpleasant  glare  from  the  light  and 
the  annoying  heat  (an  extremely  unpleasant  feature  with  metal  cases)  are  prevented. 
Heat  ventilation  is  secured  by  the  six  or  eight  holes  in  the  body,  which  are  bored  diagonally  in 
a  diverging  direction.  The  cap  on  the  top  of  the  lantern  protects  the  terminal  wires  of  the 
lamp,  the  tip  of  the  latter  being  protected  by  the  lower  cap.  The  lens  is  two-inch  focus  and  one 
inch  in  diameter,  which  gives  in  this  lantern  the  best  illuminating  effect  at  about  eight  to  nine 
inches.  The  lens  tubes  are  made  of  brass,  and  slide  one  in  the  other,  each  being  about  one  inch 
in  length. 

and  even  tea,  coffee,  and  tobacco  used  in  moderation,  if  at  all.     This 
regimen  should  also  be  continued  for  some  time  after  the  operation. 

'  A  New  Operation  for  the  Radical  Cure  of  Chronic  Purulent  Inflamma- 
tion of  the  Middle  Ear  Tract,  by  Samuel  Sexton,  M.D.  Transactions  of  the 
Amer.  Otol.  Soc,  1886. 

*  The  electro-motor  power  and  lantern  supplied  by  the  River  &  Rail  Electric 
Co.  affords  the  most  satisfactory  light  of  any  the  author  has  seen. 
24 


3Y0 


EXCISION    OF    THE    DEUM-HEAD    AND   OSSICLES. 


The  existence  of  a  narrow  and  much  curved  external  auditory  canal 
interferes  more  or  less  with  operative  procedures.  In  cases  where 
granulation  tissue  or  polypi  occupy  the  drum,  success  will  follow  sooner 
if  the  parts  are  first  brought  into  a  more  healthful  condition  by  local 
treatment.  The  writer  at  first  undertook  a  nu  mber  of  cases  exceed- 
ingly unfavorable  in  this  respect,  and  found  that  where  local  inflam- 
mation was  attended  with  free  secretion  and  active  proliferation,  the 
results  were  not  so  satisfactory  as  where  the  parts  had  been  previously 
treated.  Moreover,  where  vascularity  is  great,  the  bleeding  will  ob- 
scure the  field  of  operations. 

It  might  be  well  to  add,  finally,  that  the  operation  will  not  be  ad- 
visable during  the  menstrual  period. 


THE  OPEEATION   IX   CHRONIC    PURULENT   INFLAMMATION   OF   THE 

MIDDLE   EAR. 

The  patient  lies  on  his  back  upon  a  table  so  constructed  that  the 
head  and  back  may  be  raised  to  a  convenient  elevation  for  the  operator. 


Fig.  54. 


seated  at  the  patient's  head.  The  operating  room  is  then  darkened, 
and  the  electric  current,  illuminating  the  lantern,  turned  on.  The 
first  step  in  the  operation  consists  in  transfixing  the  membrana  tym- 
pani  behind  the  short  process  of  the  malleus  with  the  trowel-shaped 


EXCISION   OF   THE   DRUM-HEAD   AND   OSSICLES. 


371 


'I 

ir 
m 


Fig.  56. 


Fig.  55. 


Fig.  57 


Fig.  58. 


372  EXCISION  or  jhe  drum-head  and  ossicles. 

knife,  as  shown  in  Fig.  55.  TJien  the  same  instrument,  or  a  blunt- 
pointed  narrow  blade  (Fig.  56)  is  swept  around  the  margin  of  the 
tympanic  ring  posteriorly,  detaching  any  remains  of  the  drum-head 
in  this  direction.  The  same  steps  are  then  taken  in  detaching  the 
anterior  portion  of  the  drum-head,  the  transfixion  being  in  front  of 
the  short  process,  at  which  point  the  second  incision  is  begun  and 
completed  by  carrying  the  knife  around  anteriorly. 

If  the  incudo-stapedial  joint  is  intact  and  can  be  seen,  it  may  be 
divided  before  these  incisions  are  made.  If  this  is  not  previously 
done,  the  detached  tissues  behind  the  malleus  should  be  pushed  aside 
in  order  to  bring  the  parts  into  view,  when  the  division  of  the  joint 
mentioned  may  be  accomplished.  The  angular  bladed  knives  used  for 
this  procedure  are  shown  in  Figs.  57  and  58;  two  of  these  knives  will 
be  necessary,  one  for  the  right  ear  and  one  for  the  left.  The  incus,  if 
in  view,  may  mow  be  removed  with  forceps.  The  malleus  should  then 
be  freed  from  all  of  its  attachments,  such  as  tendinous  connections, 
the  tendon  of  the  tensor  tympani  muscle,  and  adhesions  arising  from 
inflammatory  processes,  to  as  great  an  extent  as  possible,  with  the 
trowel  shaped  knife.  It  is  then  seized  with  stout  dressing  or  foreign- 
body  process  as  high  up  as  possible,  and  by  gentle  traction  gradually 
detached  and  brought  away. 

The  parts  may  be  cleaned  of  blood  from  time  to  time,  as  required, 
during  the  operation,  with  tampons  of  cotton  wool  wound  on  carriers, 
and  kept  ready  at  hand.  If  the  malleus  is  seized  near  the  umbo,  in 
cases  where  the  handle  is  brittle  or  tlie  head  or  body  is  adherent,  the 
bone  may  be  broken  off  at  some  point  below  the  short  process.  Some- 
times only  the  long  process  of  the  incus  comes  into  view  after  the 
malleus  has  been  removed;  if  still  attached  to  the  stapes,  it  may  now 
be  separated  from  that  bone,  seized  with  forceps,  and  brought  away. 
But  where  it  has  long  been  separated  from  the  stapes,  its  removal  is 
by  no  means  always  easy,  since  the  long  process  may  be  absent,  or,  if 
remaining,  the  entire  bone  is  liable  to  be  displaced  and  lodged  out  of 
view  upon  the  scute  behind  the  margin  of  the  tympanic  ring.  In 
other  cases  it  becomes  still  more  displaced  backwards  towards  the  an- 
trum. The  author  is  in  the  habit  of  searching  for  this  bone,  when 
concealed  from  view,  with  along,  stout  silver  probe,  made  for  the  pur- 
pose, and  bent  at  about  a  right  angle  a  quarter  of  an  inch  or  less  from 
one  end,  the  bulb  of  the  bent  end  being  serrated  deeply  on  the  inner 
side.  A  magnifying  glass  is  used  from  time  to  time  to  bring  the 
whole  region  into  better  view.  The  removal  of  the  incus  is  not  diflBcult 
when  brought  down  into  view.  Sometimes  the  malleus  and  incus  are 
found  adherent  to  each  other,  and  come  away  together. 


EXCISION   OF   THE   DRUMHEAD   AND    OSSICLES.  373 

The  writer  first  considered  it  necessary  to  divide  the  chorda  tym- 
pani  nerve  in  all  eases  before  bringing  away  the  two  ossicles.  He  no 
longer  does  this,  however,  unless  the  nerve  becomes  entangled,  and 
drawn  down  into  view,  an  accident  that  he  is  now  able  to  avoid  in 
most  instances. 

The  operation  usually  requires  from  ten  to  fifteen  minutes  for  its 
performance  after  narcosis  is  complete.  Frequently,  however,  less 
time  is  needed. 

After  the  operation,  the  parts  should  be  gently  wiped  out,  and 
dried  with  cotton  wool,  avoiding  syringing  unless  collections  of 
inspissated  pus  are  discovered.  IE  pretty  free  bleeding  continues,  the 
fundus  may  be  syringed  out  with  water  as  hot  as  can  be  safely  used. 
Pain  is  seldom  experienced  after  the  operation,  but  it  may  be  relieved, 
if  present,  by  the  instillation  of  a  few  drops  of  a  four-per-cent  solu- 
tion of  cocaine  hydrochlorate.  Generally  very  little  inflammatory 
reaction  follows  the  operation,  though,  in  some  cases,  infiltration  of 
the  wounded  parts  may  be  expected. 

The  accompanying  table  of  cases  shows  the  results,  etc.,  of  twenty- 
nine  operations  undertaken  for  the  cure  of  chronic  otorrhoea  in 
twentyeight  patients,  in  one  case  both  ears  having  been  operated. 

Eleven  of  these  patients  were  males,  and  seventeen  females.  The 
left  ear  Avas  operated  alone  in  18  cases,  the  right  in  9,  whilst  in  1  case 
both  ears  were  operated. 

In  reviewing  the  conditions  under  which  the  operation  was  under- 
taken in  these  cases,  it  is  found  that  in  the  great  majority  of  them  a 
very  offensive  discharge  had  long  existed,  together  with  a  history  of 
frequent  "gathering  and  breaking"  in  the  ear,  often  with  invasions 
of  acute  head  catarrh,  where  swelling  of  the  drum  gave  rise  to  obstruc- 
tion to  drainage  from  the  attic  and  antrum,  the  attacks  being  at- 
ended  with  severe  pains  in  the  ear.  Usually  the  patients  were  very  deaf 
and  experienced  distressing  acoustic  phenomena,  as  autophony  and 
noises  in  the  head  and  cars. 

The  general  health  of  the  patients  was  not  good;  most  of  them  were 
from  the  run-down  class  found  in  hospital  practice.,  The  young 
children  were  generally  nervous,  peevish,  cachectic,  and  poor  sleepers, 
whilst  the  older  ones  were  neurasthenic  and  subject  to  neuralgia  about 
the  head. 

The  pathological  state  of  the  drum  in  all  cases  was  one  of  irremedi- 
able impairment  of  the  transmitting  mechanism. 


374 


EXCISION    OF    THE    DRUM-HEAD   AND   OSSICLES. 


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382  KXCISION    OF    THE    DRUM-HEAD    AND    OSSICLES. 

The  existence  of  chronic  purulent  inflammation  of  the  attic  and 
antrum  with  a  sinus  leading  out  through  the  upper  margin  of  drum- 
head, where  discharge  and  deafness  are  slight,  does  not  always  call 
for  excision  of  the  ossicles.  But  chronic  purulency  of  these  parts  that 
has  resisted  other  methods  of  treatment  for  months  or  years,  together 
with  loss  of  the  greater  portion  of  the  membrana  vibrans  and  conse- 
quent deafness,  are  conditions  that  the  operation  will  nearly  always 
relieve  and  generally  cure  so  far  as  the  otorrhcea  is  concerned. 

In  most  of  the  cases  under  discussion  the  membrana  flaccida  was 
almost  the  only  portion  of  the  drum-head  remaining.  In  some  cases, 
however,  bands,  consisting  in  part  of  the  remains  of  the  m.  vibrans 
and  in  part  of  cicatricial  tissue,  were  found  extending  in  various  di- 
rections from  the  tympanic  ring,  m.  flaccida  and  malleus,  binding  the 
dism  mtled  transmitting  apparatus  together  or  to  the  inner  wall  of 
the  tympanum.  In  the  larger  number  of  cases,  the  remains  of  the 
ossicles  and  cicatricial  structures  just  alluded  to  were  found  adhering 
to  the  inner  wall  of  the  drum  in  such  a  way  as  to  prevent  drainage 
from  the  attic  and  antrum  during  ''gatherings,"  though  the  small 
sinus  usually  present  was  sufficient  for  the  escape  of  the  ordinar}^  se- 
cretion of  these  parts. 

The  malleus  and  stapes  were  generally  present,  being  held  firmly 
in  place  by  ligament )us  and  membranous  attachments.  The  incus 
was  less  constantly  found  and  its  attachment  to  the  stapes  seldom 
remained. 

The  malleus,  or  portions  of  it,  was  usually  quite  firmly  held  in  the 
drum,  even  after  the  most  destructive  or  long-continued  suppurative 
action. 

In  19  of  the  above  recorded  cases  the  malleus  and  incus  were 
both  removed;  in  7  cases  the  malleus  alone  was  extra<3ted,  whilst 
in  3  cases  only  the  incus  was  removed.  In  many  cases  the  malleus 
handle  had  been  party  destroyed  by  caries,  a  stump  only  remaining, 
in  some  instancas  denuded,  in  others  enveloped  in  thickened  tissues. 
Sometimes  the  handle  was  covered  with  white  and  glistening  cicatri- 
cial tissue.  In  most  instances  the  incus  was  also  more  or  less  affected  by 
caries.  The  articular  surfaces  of  the  ossicles  were  generally  abnor- 
mal; very  often  ankylosed  to  each  other. 

The  incus  seemed  adherent  to  the  scute  in  some  cases — though  a 
doubt  was  entertained  as  to  whether  this  bone  might  not  have  been 
absent,  the  parts  being  beyond  the  range  of  vision  and  explored  by 
means  of  a  probe,  which,  in  touching  the  exposed  and  roughened  sur- 
face of  the  scute,  gave^^  a  rather  uncertain  impression.  In  one  case  the 
neck  of  the  malleus  was  firmly  adherent  to  the  auditory  plate. 


EXCISION    OF    THE    DRUM-HEAD    AND    OSSICLES.  383 

The  condition  of  the  stapes  cannot  always  be  determined,  since  it 
is  impossible  to  examine  it  in  situ  in  all  cases ;  it  is,  however,  prob- 
ably very  often  much  injured. 

'J'he  tympanum  was  sometimes  almost  filled  with  granulation  tissue 
or  polypoid  growths  of  greater  or  less  size,  and  .the  mucous  membrane 
lining  the  parts  was  often  greatly  thickened.  Secretions  were  very 
abundant  Avliere  such  patliological  conditions  also  existed  in  the  antrum 
and  neighboring  cellules,  especially  when  these  deep  lying  cavities 
were  large. 

In  some  of  the  cases,  the  drum-head  was  the  seat  of  a  large  heart- 
shaped  perforation,  leaving  a  narrow  rim  attached  to  the  tympanic 
ring  all  round  it. 

The  walls  of  the  middle  ear  tract  were  seldoin  entirely  free  from 
caries,  especially  the  upper  surface  of  the  scute. 

A  peculiarity  of  the  denuded  surfaces  in  this  region  is  the  white 
and  glistening  appearance  of  the  cicatricial  tissue  which  is  substituted 
for  the  periosteal  surface  when  healing  has  taken  place. 

Where  extensive  adhesions  and  greatly  thickened  tissues  were  cut 
away,  the  discharge  immediately  increased  for  a  tinie,  and  occasion- 
ally there  was  some  tenderness  of  the  tissues  for  several  days.  General- 
ly the  discharge  gradually  decreased,  and  then  ceased  altogether, 
leaving  a  non-secreting,  dermoid  surface  lining  the  entire  middle  ear 
tract  as  far  as  could  be  seen. 

The  result  in  these  29  operations  may  be  summed  up  as  follows: 
15  were  cured  and  13  improved,  whilst  1  patient  (Case  17)  passed 
from  under  observation  after  the  operation,  and  nothing  concerning 
the  result  in  his  ease  has  been  ascertained.  Of  the  15  cases  where  a 
cure  occurred,  this  result  took  place: 

In  2  cases  within  one  month  (Oases  5  and  8).' 

In  9  cases  within  two  months  (Cases  1,  4,  6,  7,  12,  15,  22,  24,  27). 

In  2  cases  within  three  months  (Cases  9  and  20). 

In  2  cases  within  six  months  (Oases  2  and  16). 

In  the  larger  number  of  the  thirteen  cases  noted  as  improved,  this  im- 
provement was  slight,  owing  to  a  carious  condition  of  the  bony  walls, 
etc.,  of  the  immediate  region,  and  some  of  them  were  under  treatment 

^  The  author  desires  to  call  attention  to  an  error  occurring  in  his  paper  on 
"  Excision  of  the  Ossicles,  etc.,"  printed  in  the  Trans,  of  the  American  Otolo- 
gical  Society,  1887.  In  the  table  of  results,  namely,  given  on  page  88  of  that 
volume,  live  cases  are  reported  as  cured  within  one  month,  and  two  cases 
within  two  months'  time.  The  mistake  in  these  numbers  was  owing  to  an 
oversight,  not  discovered  in  time  to  correct  them;  the  figures  should  be  re- 
versed. 


384  EXCISION    OF   THE    DRUM-HEAD    AND    OSSICLE3. 

a  long  time.  In  the  greater  number,  the  improvement  consists  in 
more  or  less  decrease  of  the  discharge,  but  principally  in  the  cessation 
of  the  pain,  "  gatherings,"  and  headaches. 

A  marked  improvement  in  hearing  occurred  in  consequence  of  the 
operation  in  eleven  ol  these  cases.  The  degree  of  improvement  in 
this  respect  in  each  case  may  be  seen  by  consulting  the  table  given. 
In  some  it  was  quite  remarkable,  and  it  may  be  fairly  estimated  that 
the  gain  in  hearing  power  was  from  seventy-five  to  one  hundred  per 
cent  or  more,  as  tested  by  the  voice.  Hearing  was  also  improved  for 
the  watch  and  other  high-pitched  sounds.  The  hearing  power  was 
not  always  notably  increased  immediately  after  the  operation,  but 
improved  gradually  as  a  cure  was  established. 

This  marked  improvement  in  hearing  was  quite  unexpected  by  the 
author,  and  gave  rise  to  the  conviction  that  the  operation  may  be 
recommended  for  deafness  alone  in  many  cases  where  the  drum  is 
obstructed  by  the  results  of  chronic  purulent  inflammation,  though 
all  discharge  may  have  ceased. 

Case  24,  undertaken  for  the  relief  of  deafness,  is  a  good  example 
of  this  kind.  The  patient,  a  young  dressmaker,  who  had  lost  a  sit- 
uation on  account  of  deafness,  was,  owing  to  the  result  obtained  by 
the  operation,  enabled  to  resume  her  work. 

The  sense  of  taste  was  more  or  less  affected  in  those  cases  where  the 
chorda  tympani  had  been  divided  in  the  operation;  recovery,  how- 
ever, always  took  place  in  a  short  time.  In  many  of  the  cases  the 
nerve  had  been  previously  impaked  or  totally  destroyed  by  suppura- 
tive inflammation. 

Reproduction  of  the  drum-head  did  not  take  place  in  any  of  the 
cases. 

General  health  was  nearly  always  much  improved;  in  two  phthisi- 
cal subjects  the  cough  lessened  in  one  and  ceased  altogether  in  the 
other,  whilst  both  gained  much  in  strength  and  weight. 

In  children  the  good  effect  on  health  was  very  marked;  anorexia, 
restlessness,  febrile  movements,  etc.,  which  previously  existed,  ceased 
after  the  operation.  Indeed,  this  would  be  expected  on  the  cessation 
or  abatement  of  otorrhcea  and  earache. 

In  short,  the  important  results  of  excision  of  the  remains  of  the 
transmitting  mechanism  of  the  ear  are  the  preventioji  of  recurrent 
accumulations  of  mucous  or  purulent  matter  in  the  attic  of  the  an- 
trum, the  cure  of  otorrhcea  together  with  the  relief  of  the  attendatit 
pain,  deafness,  and  distressing  acoustic  phenomena. 

In  regard  to  after-treatment,  it  is  important  to  keep  up  the 
patient's  general  health,  and  to  as  great  an  extent  as  possible  strive 


EXCISION    OF    THE    DKUM-HEAD    AND    OSSICLES.  385 

to  abate  any  inflammatory  (catarrhal)  disturbances  of  the  naso- 
pharynx and  middle  ear  tract.  Carious  teeth  should,  if  greatly 
damaged  or  '' dead/^  be  removed.  In  several  of  the  author's  cases, 
the  cure  was  greatly  delayed  by  the  presence  of  diseased  ('Mead") 
teeth,  causing  reflected  irritation. 

Where  caries  of  the  osseous  structure  of  the  middle  ear  tract  ex- 
ists, or  where  a  large  pathological  cavity  comprising  the  attic,  an- 
trum, and  cellules  is  lined  with  an  actively  secreting  surface,  the 
treatment  must  be  directed  to  keeping  down  granulation  tissue  whilst 
the  transformation  of  the  mucous  lining  to  a  dermoid  condition  takes 
place.  In  some  very  much  run-down  persons,  all  treatment  may,  for 
a  time  at  least,  prove  unavailing,  bat  ''gatherings  "  no  longer  occur, 
since  drainage  is  no  longer  interfered  with.  In  one  case,  under  most 
unfavorable  conditions,  whilst  drainage  remained  good,  purulency 
continued  and  granulation  tissue  refilled  the  attic  in  a  short  time  after 
the  operation.  Some  bands,  moreover,  subsequently  were  found  to 
connect  the  tissues  on  the  upper  margin  of  the  tympanic  ring  with 
the  inner  wall  of  the  tympanum. 

Active  measures  should  be  avoided  at  first,  but  later  on  salicylic  or 
boracic  acid  powder  may  be  employed.  The  peroxide  of  hydrogen 
has  its  use  in  some  cases.  Alcohol  has  not  been  found  useful  in  keep- 
ing down  granulation  tissue  in  these  cases.  The  persistency  of  dis- 
charge after  the  operation  usually  depends  upon  a  general  catarrhal 
condition  of  the  upper  air-tract  in  cachectic  subjects,  especially  where 
caries  of  the  bone  exists. 

The  operation  has  a  wide  field  of  usefulness  among  the  so  called 
deaf-mute  class.  Many  of  these  persons  in  whom  treatment  has  been 
abandoned,  especially  after  cessation  of  the  otorrhoea,  could  doubt- 
lessly be  restored  to  much  better  hearing. 

THE     OPEEATION    IN     CHRONIC     NON-SUPPURATIVE    (CATARRHAL) 
INFLAMMATION    OF   THE    MIDDLE    EAR. 

The  author,  having  found  that  hearing  was  greatly  improved  in 
some  of  the  cases  where  the  surgical  procedures  described  above  had 
been  undertaken  for  the  relief  of  otorrhcea,  decided  to  extend  its 
benefits  to  cases  of  deafness,  vertigo,  and  noises  in  the  ears,  espe- 
cially when  occurring  in  sclerosis  of  the  transmitting  mechanism. 

Believing  that  in  certain  cases  deafness  was  due  to  rigidity  from 

ankylosis  in  some   part   of  the  ossicular  chain  of  the  transmitting 

mechanism,  he  concluded  to  make  a  free  opening  with  sulphuric  acid 

in  the  posterior-superior  quadrant  of  the  drum-head,  exposing  the 

25 


386  EXCISION   OF    THE    DRUM-HEAD    AND    OSSICLES. 

incudo-stapedial  joint,  which  could  then  be  disarticulated.  Ac- 
cordingly, several  patients  were  treated  in  this  manner,  the  opening 
in  the  drum-head  being  allowed  afterwards  to  close  up.  In  order  to 
prevent  a  reunion  of  the  disunited  surfaces,  the  end  of  the  long 
process  of  the  incus  was  amputated.     (See  Fig.  59.) 

Hearing  and  noises  in  the  ear  were  found  to  be  much  relieved  by 
this  operation,  but  on  closure  of  the  opening  in  the  drum-head, 
deafness  was  almost  as  great  as  before,  though  the  relief  of  the  sub- 
jective symptoms  remained. 

In  one  instance  (see  Case  30),  however,  operated  in  November,  1 886^ 


Fig.  59.— The  Author's  Instrument  for  amputating  the  long  process  of  the  incus,  con- 
sisting of  a  small  steel  canula.  fastened  to  a  handle  at  nearly  a  right  angle,  and  having  a  ring- 
like end.  This  ring  or  loop  is?  slipped  over  the  long  process,  when  amputation  is  accompUshed 
by  pushing  forward  the  knife  (which  slides  concealed  in  the  canula).  by  making  pressiu-e  with 
the  thumb  on  the  knob.    The  action  is  somewhat  similar  to  that  of  a  tonsillotome. 

in  which  the  transmitting  mechanism  was  thus  set  free,  so  to  speak, 
the  opening  remaining,  the  result  was  so  brilliant  that  the  writer 
was  encouraged  to  perform  the  operation  of  excision  of  the  drum- 
head, malleus,  and  incus,  in  the  hope  that  preventive  measures  might 
be  taken  against  a  reproduction  of  the  drum-head.  Profiting  by  his 
own  experience  in  operations  on  the  ear,  as  well  as  that  of  other 
aural  surgeons,  he  has  met  with  greater  success  than  could  have  been 
ho{>ed  for. 


EXCISION    OF    THE    DRCM-HEAD    AND    OSSICLES.  387 

Tlie  indications  for  the  operation  comprise  great  impvairment  of 
the  functions  of  the  transmitting  mechanism  from  chronic  inflam- 
mation (catarrhal)  of  the  drum,  or  as  a  result  of  acute  suppurative  or 
non-suppurative  action  in  the  organ;  whereby  the  mechanism  no 
longer  facilitates  sound  transmission,  but  is  rather  a  hindrance 
thereto.  The  degree  of  deafness  for  the  relief  of  which  we  may 
operate  differs  somewhat  in  each  case,  the  conditions  of  age  and 
occupation  influencing  patients  variously. 

Persons  who  cannot  distinguish  words  in  conversation  of  a  loud 
tone  at  one  or  two  feet  distance,  without  the  aid  of  lip-reading,  may 
generally  be  benefited  by  the  operation.  These  would,  according  to 
the  writer's  experience,  be  able  to  iiear  after  the  operation  ordinary 
conversation  at  from  two  to  twenty  feet,  according  to  circumstances. 
Hearing  for  voice,  after  excision  of  the  transmitting  mechanism,  im- 
proves more  in  respect  to  cognizance  than  to  definition,  so  to  speak; 
thus  plainly  spoken  words  are  heard  almost  as  well  at  twenty  feet  as 
at  ten  feet,  but  whilst  heard  more  loudly  they  are  not  proportionally 
80  well  understood.  The  gain,  however,  in  some  instances  is  much 
greater  than  this.  Persons  having  their  hearing  considerably  restored 
by  the  operation  are  liable  to  soon  forget  how  great  the  improvement 
has  bsen,  but  in  some  instances,  where  reproduction  of  the  drum-head 
has  occurred  and  the  patient  has  lapsed  into  the  same  state  as  be- 
fore the  operation,  the  return  of  deafness  has  been  keenly  felt.  In 
advising  the  operation,  it  is  well  to  explain  in  detail  how  little  may 
sometimes  be  gained  ;  yet  how  important  that  little  may  be  is  shown, 
as  just  stated,  by  its  sudden  loss  again.  Where  deafness  is  progres- 
sive, we  may  confidently  expect  to  arrest  its  progress,  i.  e.,  to  judge 
from  the  cases  already  observed,  the  progress  of  chronic  inflamma- 
tion ceasing  after  the  mucous  membrane  of  the  drum  undergoes  der- 
mic transformation. 

The  writer  has  been  forced  to  the  conclusion  that,  on  removal  of 
the  drum-head,  malleus,  and  ijicus,  sound  enters  the  labyrinth  through 
either  or  botli_windows,  since  he  has  witnessed  great  improvement 
from  an  opening  made  in  the  drum-head  without  separation  of  the 
incus  from  the  stapes.  But  inasmuch  as  no  way  is  at  present  known 
of  ascartaining  bsforehaul  whether  fixation  of  the  stapes  exists  in 
any  given  case,  it  is  advisable  to  separate  this  bonelet  from  the  incus 
after  perforation.' 

'  The  author  has  a  case  under  observation  where  the  incudo-stapedial  artic- 
iilation  was  left  iutact  after  removal  of  the  posterior  segment  of  the  drum- 
head, in  which  hearing  is  much  improved:  he  hopes,  by  disarticulating  this 
joint,  soon  to  be  able  to  decide  whether  the  round  window  alone  will  admit 
sound  waves  in  this  case. 


388  EXCISION    OF    THE    DRUM-HEAD    AND    OSSICLES. 

The  writer's  experience  in  operating  for  the  relief  of  subjective 
symptoms  only  is  more  limited.  It  has  been  found,  however,  that, 
where  they  existed,  vertigo  and  noises  in  the  ear  have  been  alleviated 
or  cured  entirely  by  excision.  Where  very  great  relaxation  of  the 
transmitting  mechanism  exists,  giving  rise  to  severe  autophonia.  noises, 
yertigo,  etc.,  the  operation  would,  therefore,  seem  to  be  indicated.  As 
a  rule,  it  is  probable  that  the  earlier  in  life,  as  well  as  earlier  in  the  dis- 
ease itself,  the  operation  is  done,  the  more  successful  it  will  be. 

Method  of  Operating. — The  operative  procedures  in  chronic  (catar- 
rhal) inflammation  of  the  middle  ear  are  somewhat  similar  to  those 
described  for  otorrhcea.  The  author's  first  method  differed  from 
that  of  the  German  surgeons  in  several  particulars.  A  small  quan- 
tity of  acidum  snlphu7'icum  '  (less  than  a  drop)  was  first  applied  to 
the  posterior  segment  of  the  drum-head,  by  means  of  a  minute  mop 
of  cotton-wool  wound  upon  the  end  of  a  silver  or  aluminium  probe. 
Then,  with  a  silver  piobe,  the  cauterized  area  was  quickly  broken 
down,  thus  making  a  large  opening  without  any  hemorrhage  to  obscure 
the  parts,  and  render  the  next  step  of  the  operation,  which  is  one  of 
delicacy,  difficult.  He  now,  however,  detaches  the  drum-head  by 
simple  incision  all  around,  leaving  the  flaps  attached  to  the  handle  of 
the  malleus.  The  incudo-stapedial  articulation  is  then  divided  with 
the  knives  shown  in  Figs.  57  and  58.  This  is  usually  accomi)anied 
by  quite  a  loud  and  distinct  ''click,"  and  leaves  the  detached  end  of 
the  long  arm  of  the  incus  in  view.  A  bent  silver  probe  should  now 
be  passed  behind  the  long  arm  of  the  incus  to  make  sure  of  its  separation 
from  the  stapes.  If  the  probe  be  gently  passed  over  its  surface,  and 
some  of  its  envelope  detached,  it  will  generally  present  a  glistening, 
white  appearance,  and  is  thus  easily  distinguishable.  It  may  now  be 
brought  down  with  forceps,  on  slight  traction  being  made.  The  re- 
maining attachments  of  the  drum  head  should  then  be  separated  with 
the  knife  shown  in  Fig.  55,  and,  together  with  the  malleus,  removed, 
as  in  the  previously  described  operation  for  purulency.  The  writer 
formerly  did  not  remove  the  incus,  as  mentioned  above,  until  after 
the  drum-head  and  malleus  had  been  taken  away.  Finding,  however, 
that  the  latter  procedure  was  liable  to  displace  the  incus,  which  could 
not  afterwards  be  found,  he  has,  of  late,  removed  the  incus  as  above 
described.  In  some  cases,  the  incudo-stapedial  articulation  cannot  be 
brought  into  view;  we  must  then  pass  the  angular  knife  used  for  this 
purpose  backwards  through  the  opening  in  the  drum-head,  the  blade 
in  a  horizontal  position,  until  it  impinges  against  the  descending  arm 

»  Method  of  J.  Simrock,  Med.  Record,  Mar.  27th,  1875. 


EXCISION    OF    THE    DRUM-HEAD    AND    OSSICLES.  389 

of  the  incus.  It  is  then  turned  up  perpendicularly  and  passed  about 
a  line  or  less  further  inward,  and  beyond  this  bone,  then  turned  back 
again  to  its  first  position.  If  now  gently  withdrawn,  the  blade  will  be 
arrested  by  the  long  arm  of  the  incus,  when,  by  cutting  downwards, 
disarticulation  is  accomplished. 

The  author  has  found  that  the  chorda  tympani  nerve  is  usually  not 
disturbed  by  this  operation,  especially  when  the  incus  is  first  removed. 
If,  however,  it  happens  to  be  drawn  down  into  view/a  section  of  it  may 
be  removed,  the  resulting  disturbance  in  taste  being  of  short  duration. 

Where  the  incus  cannot  readily  be  found,  protracted  search  should 
be  avoided,  since  its  retention  could  not  be  so  productive  of  harm  as 
rude  attempts  at  removal;  experience,  moreover,  shows  that  removal 
of  the  incus  is  not  necessary  to  a  favorable  result  of  the  operation. 

The  drum  should  be  carefully  cleaned  with  absorbent  cotton  after 
the  operation.  There  is  but  little,  if  any,  pain  experienced  by  the 
patient  on  coming  out  of  the  narcosis,  and  a  drop  of  a  four-per-cent 
solution  of  cocaine  put  into  the  drum  is  sufficient  to  allay  any  dis- 
comfort. The  free  use  of  this  drug  is  to  be  avoided,  since  a  few  drops 
may  give  rise  to  vertigo,  nausea,  and  collapse.  Syringing  is  not  ad- 
visable, but  the  canal  should  be  closed,  after  drying,  with  a  pellet  of 
cotton-wool. 

It  seems  almost  unnecessary  to  practise  antiseptic  precautions  in 
this  operation,  where  air  enters  the  parts  both  from  without  and 
through  the  Eustachian  tube;  yet  suppuration  is  very  slight  in  most 
cases  and  in  many  does  not  occur  at  all. 

In  five  or  six  days,  any  tissues  left  partly  detached  during  the  opera- 
tion become  neci'otic  and  are  discharged;  the  quantity  is  very  small, 
usually  consisting  of  shreds  of  the  drum-head. 

Chiselling  away  a  portion  of  the  sulcus  tympanicus  is  quite  unneces- 
sary ;  indeed,  the  procedure  is,  from  the  irritation  caused,  likely  to 
favor  reproductive  action. 

The  following  cases  of  the  author's  are  examples  of  this  operation: 

Case  30.' — Female,  27  years  of  age,  had  been  suffering  from  deaf- 
ness in  the  right  ear  for  some  two  years  past,  accompanied  by  tinni- 
tus. The  operation,  undertaken  on  November  11th,  1886,  (ether), 
consisted  in  making  a  large  opening  with  sulphuric  acid  in  the  pos- 
terior segment  of  the  right  drum-head,  and  dividing  the  incudo- 
stapedial  joint.  To  prevent  reunion  of  the  latter,  the  detached  end 
of  the  long  process  of  the  incus  was  amputated.  The  parts  healed  up 
quickly,  leaving  a  large  opening  in  the  drum-head  through  which  the 
lower  end  of  the  long  arm  of  the  incus  and  the  stapes  could  now  be 

'  Cases  30,  31,  35  were  exhibited  in  the  December  meeting  of  the  Practitioners' 
Society  of  New  York,  1887.     See  N.  Y.  Medical  Record,  Dec.  31st,  1887. 


390  •       EXCISION    OF    THE   DRUM-HEAD   AND    OSSICLES. 

plainly  seen.  Tlie  patient  could  previously  hear  shouting  only  in  the 
right  ear  at  twenty  feet  as  noise;  she  can  hear  now  ordinary  voice 
"beyond  twenty  feet.  There  is  a  general  improvement  in  the  health 
of  the  patient,  and  the  tinnitus  ceased  immediately  after  the  operation. 

Case  31. — Male.  17  years  of  age,  had  been  deaf  since  infancy. 
Operation  under  ether,  February  16th,  1887.  The  entire  left  drum- 
head and  the  malleus  were  removed,  and  the  incus  was  separated 
from  the  stapes.  The  parts  were  two  mouths  in  healing,  since  there 
was  a  strong  tendency  to  reproduction,  and  the  newly  developed  tis- 
sues were  removed,  frequently  as  soon  as  formed.  The  result  of  the 
operation  was  as  follows.  Before  excision  he  heard  ordinary  conver- 
sation at  one  foot  from  either  ear,  but  worse  in  the  left  ;  very  loud 
Toice  at  four  feet  in  both  ears.  Watch  heard  in  both  |^.  After  the 
operation,  ordinary  voice  heard  at  five  feet,  loud  at  twenty  feet ;  watch 
-y^j.  Patient  relies  now  entirely  on  the  left  ear,  tlie  right  having  be- 
come gradually  worse. 

Case  32. — Female,  24  years  of  age,  had  been  deaf  since  childhood 
in  both  ears.  Patient  is  mentally  a  dull  and  stupid  person.  Many 
carious  teeth.  General  catarrhal  condition  of  naso-pharynx.  Opera- 
tion, June  23d,  1887.  Ether.  Left  ear.  Whole  of  drum-head  and 
malleus  excised.  Incus  not  removed.  There  was  some  slight  amount 
of  reaction  in  this  case,  which,  however,  caused  very  little  trouble  to 
the  patient.  No  reproduction  of  drum-head.  The  improvement  in 
hearing  was  considerable.  Before  the  operation,  she  heard  in  the  left 
ear  only  loud  voice  at  *two  feet,  shouting  at  six  feet  distance.  After 
excision,  she  could  hear  ordinary  conversation  voice  very  well  at  three 
feet  and  fairly  well  at  six  feet.  Owing  to  the  patient's  neglect  and  ex- 
posure, also  the  constant  reflected  irritation  in  the  ear  from  the  teeth, 
a  good  deal  of  the  improvement  was  subsequently  lost.  She  hears 
now  ordinary  voice  at  two  feet  and  loud  at  ten  feet. 

Case  33. — Male,  40  years  of  age,  a  sailor  by  occupation,  had  been 
suffering  from  deafness  for  some  years,  in  both  ears,  but  had  noticed 
this  during  the  past  six  months  more  especially;  much  tinnitus. 
Many  bad  teeth.  Chronic  pharyngitis.  Patient  is  practically  stone 
•deaf  in  the  left  ear ;  can  hear  loud  voice  in  the  right  (after  Politzer) 
at  twenty  feet  distance.  Operation,  July  7th,  1887.  Ether.  Ex- 
cision of  entire  left  drum-head,  malleus,  and  incus.  Hemorrhage 
slight.  Reaction  very  slight.  Some  little  mucous  discharge  followed, 
lasting  but  a  few  days.  Hearing  in  left  ear  impoved  to  plain  ordi- 
nary voice  at  two  feet  distance,  after  excision.  Eeproduction  of  the 
drum-head  began  ten  days  after  operation  and  was  complete  by 
August  1st.  Patient  then  went  to  sea,  passing  from  under  observa- 
tion. He  thought  (when  last  seen)  that  his  hearing  was  better  than 
before  the  operation,  but  this  is  not  proven  by  an  examination  of  his 
hearing  power. 

Case  34. — Female,  22|  years  of  age,  had  been  afflicted  with  deaf- 
ness in  both  ears  for  the  past  five  or  six  years.  Is  subject  to  colds  in 
the  head,  headache,  dizziness,  tinnitus  aurium.     Irregular  menses. 


EXCISION    OF    THE    DRUM-HEAD    AND    OSSICLES.  .  391 

She  is  rather  neuropathic,  run-down  in  general  health,  although  her 
appearance  is  that  of  a  pretty  healthy  person.  Has  chronic  pharyn- 
gitis. Two  days  before  the  operation,  an  application  of  acid,  sulph. 
was  made  to  the  drum-head  of  riglit  ear,  and  on  an  opening  being 
produced,  the  hearing  in  that  ear  improved  to  low  ordinary  voice  at 
four  feet  distance.  Before  she  could  not  hear  even  shouting  in  this 
ear  at  the  same  distance. 

Operation,  August  1st,  1887.  Etlier.  Excision  of  right  drum- 
head, malleus,  and  incus.  Reactive  inflammation  which  followed  was 
slight.  On  August  3d,  patient  could  hear  low  voice  at  five  feet,  or- 
dinary .voice  at  ten  feet,  and  loud  voice  at  twenty  feet  distance,  in 
the  operated  ear.  August  25th,  ordinary  voice  heard  at  fifteen  feet 
in  riglit  ear.  September  2d,  sermon  at  church  easily  understood. 
Low  voice  heard  at  ten  feet  distance.  The  discharge,  following 
operation,  ceased  in  three  weeks.  Partial  regeneration  of  drum- 
head followed,  but  then  ceased,  leaving  a  large  irregular  opening 
wliich  did  not  close.  Condition  of  patient,  who  lives  in  the  West,  was 
the  same  when  heard  from  several  months  later. 

Case  35. — Female,  32  years  of  age.  There  had  been  a  gradual  loss 
of  hearing  power,  on  account  of  chronic  catarrhal  inflammation,  for 
the  past  three  years,  especially  in  the  right  ear.  Patient  was  obliged 
to  give  up  several  situations  on  account  of  this.  Hearing  in  right 
ear  :  ordinary  voice  at  ten  inches,  loud  voice  at  five  feet,  and  very 
loud  voice  at  fifteen  feet. 

Operation,  November  10th,  1887.  Ether.  Drum-head  and  mal- 
leus of  right  ear  excised.  Incus  not  removed.  Slight  local  reaction. 
No  pain  ;  only  a  slight  serous  discharge,  and  a  diminution  of  the 
sense  of  taste  on  the  right  side  of  tongue  for  a  few  days.  Parts 
healed  rapidly,  leaving  a  free  opening  into  the  drum.  Hearing  after 
the  operation  in  right  ear  :  ordinary  voice  at  five  feet  ;  also  at  ten 
and  twenty  feet,  but  less  accurately.  The  opening  into  the  drum 
closed  in  January,  1888,  the  patient  experiencing  no  loss  of  hearing. 
The  former  opening  is  closed  by  a  manometric  membrane  which 
moves  correspondingly  on  expiration  and  inspiration,  and  is  so  thin 
that  it  gives  way  on  slight  pressure  with  a  probe. 

Case  36. — Male,  42  years  of  age,  had  been  troubled  with  deafness 
since  the  age  of  thirteen  years,  after  an  attack  of  typhoid  fever. 
Since  the  age  of  twenty-two,  he  cannot  hear  ordinary  conversation  at 
all.  Hearing  :  ordinary  words  heard  on  contact  in  both  ears.  Ope- 
ration, January  4th,  1888.  Ether.  Excision  of  right  drum-head 
and  malleus.  Incus  not  removed.  No  reaction.  The  day  after, 
street  noises,  rattling  of  dishes,  etc.,  were  heard  for  the  first  time  in 
many  years,  and  very  painfully  too.  Could  hear  now  ordinary  voice 
at  three  feet,  loud  voice  at  ten  feet. 

There  is  no  tendency  to  reproduction. 

In  a  number  of  other  operations  the  result  has  been  similar  to  the 
above,  but  they  are  still  under  observation  at  the  date  of  the  present 
writing. 


392  EXCISION  or  the  drum-head  and  ossicles. 

Case  37. — Seven  years  ago,  this  lacl}^  33  years  of  years,  began  to  ex- 
perience very  decided  deafness,  commencing  in  the  left  ear.  Slie  was 
referred  to  the  writer  by  Professor  Austin  Flint,  who  previously  had 
found  it  advisable  to  send  her  to  the  mountains  on  account  of  her  run- 
down condition.  Whilst  out  of  .town,  a  severe  head  cold  was  followed 
by  much  deafness  in  both  ears,  from  which  recovery  was  never  com- 
plete. 

Examination  showed  both  drum-heads  to  be  largely  cicatricial  and 
of  defective  development.  The  first-named  condition  was  due  to  se- 
vere suppurative  inflammation  in  infancy,  following  scarlet  fever. 
No  improvement  occurring  in  the  deafness;  the  patient  desired  to  be 
operated  for  excision.  This  was  done  on  the  right  ear,  January  12th, 
1888,  under  ether  narcosis,  the  drum-head  and  malleus  being  re- 
moved. 

Some  suppurative  action  following  the  operation,  the  parts  healed 
slowly,  leaving  at  the  end  of  two  months  a  free  opening  of  triangular 
shape  in  the  anterior  aspect  of  the  redeveloped  membrane.  The 
noises,  which  had  been  annoying  before,  disappeared  entirely. 
Hearing  before  the  operation  in  right  ear,  very  loud  voice  only  at 
five  and  ten  feet.  Hearing,  since  recovery,  ordinary  voice  five  at  feet  ; 
moderately  loud  voice  at  twenty  feet.  Hearing  for  high-pitched 
sounds  of  all  kinds  increased  in  even  a  greater  degree  than  for  voice. 

These  tests,  however,  by  no  means  convey  an  idea  of  the  value 
placed  upon  the  improvement  experienced  by  the  patient  in  the  con- 
verse of  every-day  life. 

As  a  result  of  exposure  during  very  inclement  winter  weather,  de- 
cided suppuration  came  on  in  three  cases,  and  in  two  of  these  there 
was  otitis  externa  lasting  for  several  days.  Where  suppuration  was 
thus  excessive,  reproduction  was,  seemingly,  prevented.  Extreme 
care  was  exercised,  however,  in  all  instances  to  prevent  suppuration, 
and  irritation  of  the  parts  in  any  way;  some  cases  were  not  even 
wiped  out,  the  slight  discharge  being  allowed  to  become  inspissated. 
Where  crusts  were  thus  formed  on  the  inner  end  of  the  canal  and 
over  the  margin  of  the  remaining  rim  of  the  drum-head,  the  fundus 
gave  the  appearance  of  having  been  closed  in  by  reproduction.  On 
finally  detaching  these  crusts,  however,  a  large  opening  remained. 

After  healing  has  taken  place,  the  mucous  membrane  undergoes 
dermoid  transformation,  its  sensitive  mucous  surface  having  dis- 
appeared. 

The  operation  was  more  successful  as  regards  maintaining  an  open- 
ing in  the  drum-head  in  persons  of  slight  build,  and  who  were  not 
given  to  the  use  of  stimulants  and  the  consumption  of  a  large  amount 
of  meat.  The  existence  of  advanced  atrophic  inflammation  was,  per- 
haps, n)ore  favorable  to  good  results  than  the  hypertrophic  variety,  or 


EXCISION    OF    THE    DRUM-HEAD    AND    OSSICLES.  393 

when  chronic  (catarrhal)  processes  were  still  active,  though  improve- 
ment, as  to  hearing  alone,  was  decided  in  these  latter  cases. 

The  operation  is,  in  tlie  opinion  of  the  author,  one  without  danger, 
if  ordinary  precautions  are  observed.  Now  that  we  may  afford  per- 
manent passage  for  sound  where  obstruction,  in  cases  of  sclerosis 
of  the  drum,  prevents  its  entrance,  a  wide  field  for  the  improvement 
of  hearing,  in  certain  cases  otherwise  irremediable,  is  opened.  When 
the  proper  precautions  are  observed  and  subsequent  treatment,  with 
due  attention  to  the  physical  condition  of  the  patient,  conducted 
with  care,  the  operation  will  be  found  as  successful  as  any  in  the  do- 
main of  surgery. 


PART    FOURTH. 

MISCELLANEOUS   ARTICLES. 


CHAPTER    XYIII. 

The  education  of  school  children  with  defective  hearing.     Remarks  on  the 
extent  of  deafness  in  the  schools.     Deafness  among  school  teachers. 

THE    EDUCATION    OF    SCHOOL    CHILDREN    WITH    DE- 
FECTIVE  HEARING. 

School  children  having  aural  defects  may  be  divided  into  two 
^classes,  the  partially  deaf,  and  totally  or  almost  totally  deaf.  Either 
one  of  these  groups  is  susceptible  of  an  important  subdivision,  which 
space  will  only  permit  of  mention  being  made  here,  namely,  the  men- 
tally feeble  and  the  mentally  sound.  Education  of  the  feebleminded 
is,  of  course,  much  more  difficult,  whatever  the  degree  of  deafness 
may  be. 

The  subject  of  special  instruction  for  the  deaf  is  scarcely  less  im- 
portant than  that  of  education  itself,  and  the  comparatively  slight 
attention  given  it  seems  to  Justify  its  consideration  here  somewhat  at 
length.  Since  the  writer  first  discussed  the  subject  in  a  brochure 
published  by  the  Bureau  of  Education  in  1881,  several  writers  at 
home  and  abroad  have  taken  the  subject  up,  notably  Weil,'  of  Stutt- 
gart, who  examined  some  four  thousand  five  hundred  school  children 
with  reference  to  their  hearing  power. 

Causes  of  deafness  among  school  children.  The  sense  of  hearing  is 
impaired  by  so  many  causes  to  which  children  are  exposed,  many  of 
them  almost  unavoidable,  that  it  is  unusual  to  meet  with  a  child  that 
has  not  experienced  some  aural  disease.  If  we  accept  the  statement 
as  approximately  correct,  that  of  the  entire  population  not  more  than 
five  in  every  hundred  possess  unimpaired  hearing,  some  idea  at  least 
can  be  formed  of  the  prevalence  of  this  defect  in  youth. 

The  causes  of  deafness  among  school  children  are  similar  to  those 
affecting  other  youths;  thus  blows,  frost  bite,  and  eczema  of  the  auri- 
cle are  not  uncommon.  The  presence  of  wax  or  foreign  bodies  in  the 
external  auditory  canal  frequently  causes  deafness.     Boxing  and  pull- 

»  Archives  of  Otology,  1882. 


398  THE    EDUCATIOX   OF   DEAF   SCHOOL   CHILDREN. 

ing  the  auricle  as  a  means  of  corporal  punishment  often  injures  the 
drum-head,  and  gives  rise  to  more  or  less  permanent  injury  of  the 
organ.  Some  affections  are  even  more  severe,  attacking  the  deeper 
pans  of  the  ear  or  even  the  brain,  as  the  otitis  media  of  scarlet  fever, 
or  cerebro-spinal  meningitis  which  invades  the  inner  ear  or  the  audi- 
tory nerve.  A  large  number  of  ear  affections  in  children  arise  from 
nervous  sympathy,  where  the  entire  mucous  tract  of  the  head  usually 
becomes  the  seat  of  inflammation  as  well  as  the  ear.  To  the  reflected 
irritation  arising  from  second  dentition  and  the  premature  decay  of 
teeth,  and  in  the  summer  months  to  bathing  in  rivers  and  in  the 
ocean,  many  aural  troubles  are  due.  Many  of  the  ear  affections  of 
children  are  well  known  to  leave  permanent  injury,  and  persistent 
offensive  discharge  is  a  common  sequel. 

Some  of  the  symptoms  of  eai' disease  among  children,  though  simi- 
lar to  those  occurring  in  other  subjects,  are  of  special  importance, 
since  thev  prevent  the  scholar  from  directing  his  attention  to  study. 
The  more  important  are  autophonia,  tinnitus  aurium,  "numbness,"' 
and  the  like. 

The  antophonons  voice  sounds  so  alarmingly  to  children  that  they 
frequently  avoid  speaking  altogether;  when  silence  is  thus  main- 
tained, the  child  is  called  "  dumb/'  It  has  been  the  writer's  experi- 
ence to  have  many  patients  of  this  kind  brought  to  the  infirmary  by 
their  parents,  and  it  has  not  infrequently  come  out  at  the  examina- 
tion that  such  patients  have  been  severely  punished  for  supposed  stu- 
pidity. This  condition  of  the  hearing  organ  is  by  no  means  of  infre- 
quent occurrence,  and  the  teacher  should  consider  its  possible 
influence  on  a  child's  behavior  before  condemning  it  as  perverse  or 
wilfully  disobedient. 

Noises  in  the  head  are  very  confusing  to  children  who  experience 
them  in  some  degree  with  almost  every  cold  in  the  head,  and  they  are 
almost  inseparable  from  all  kinds  of  aural  affections;  they  manifest 
themselves  in  an  infinite  variety  of  phases,  almost  every  patient  de- 
scribing his  own  experience  differently;  they  are  thus  said  to  resem- 
ble ringing  of  bells,  the  roar  of  the  sea  or  of  the  wind  among  the 
trees,  the  buzzing  of  insects,  the  escape  of  steam,  etc.  To  some  these 
noises  seem  so  loud  that  rest  cannot  be  obtained.  Where  long  neg- 
lected discharge  from  the  ear  exists,  the  distress  from  tinnitus  is  often 
very  great  indeed. 

The  above  by  no  means  presents  in  their  strongest  light  the  trou- 
bles that  children  experience  when  the  sense  of  hearing  is  perverted; 
it  may,  however,  serve  to  show  that  they  are  subject  to  some  very 
distressing  symptoms  without  always  being  able  to  make  their  suffer- 


THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN.  39^ 

ings  known ,  such  facts,  in  the  writer's  experience,  only  being  elicited 
from  the  uninformed  and  apprehensive  patient  by  the  most  pains- 
taking examination. 

DEFECTIVE    SCHOOL  HYGIENE. 

That  we  have  a  faulty  system  of  school  hygiene  no  one  familiar 
with  the  facts  will  deny;  and  the  remark  is  equally  true  both  as  re- 
gards the  construction  of  our  public  school  houses  and  the  personal 
care  of  school  children. 

When  we  are  appealed  to  as  humanitarians  to  provide  hospital  ac- 
commodations for  the  pauper  class,  no  means  are  spared  in  the  plan- 
ning and  erection  of  healthful  buildings  for  their  use,  but  when 
school  houses  are  to  be  constructed — where  both  body  and  mind 
should  be  aided  in  development,  prepared,  one  may  say,  to  enter  the 
struggle  for  "  the  survival  of  the  fittest" — their  erection  is,  it  is  to 
V  be  feared,  too  often  intrusted  to  the  political  contractor,  whose 
knowledge  in  building  is  chiefly  confined  to  "  making  it  pay." 

It  is  to  be  hoped,  however,  that  time  will  correct  these  abuses,  and 
in  the  mean  while  the  best  must  be  done  with  such  buildings  as  have 
been  given  us.  These  are  not,  perhaps,  so  faulty  but  that  better 
hygienic  regulations  could  contribute  very  much  to  their  comfort  and 
healthfulness. 

It  will,  however,  be  useless  to  devise  plans  for  the  heating  and  ven- 
tilation of  school  houses  so  long  as  negligence  and  apathy  prevail  on 
tlie  part  of  those  who  have  such  matters  in  charge;  these  seem  to 
regard  the  heating  of  apartments  occupied  by  school  children  as  con- 
tributing sufficiently  to  their  personal  well-being.  It  is,  no  doubt, 
honestly  believed  by  many  to  be  more  important  to  maintain  a  cer- 
tain established  temperature  in  the  school  room  than  to  protect  the 
individual  from  injudicious  exposures  to  draughts  or  to  an  undue 
elevation  of  temperature,  as  the  case  may  be.  There  has  been  so 
much  said  about  the  ills  that  arise  from  breathing  foul  gas  and  dust, 
which  are  believed  to  poison  the  blood  or  irritate  the  air  passages,  and 
so  little  said  about  the  dangers  of  draughts  of  air,  that  the  latter  are 
liable  to  be  overlooked  in  the  anxiety  to  avoid  the  evils  attendant  on 
the  former.  Too  much  care  cannot  be  taken,  obviously,  to  avoid  the 
inhalation  of  deleterious  matters,  but  certainly  equal  care  should  be 
exercised  to  guard  against  the  injurious  effects  of  overheating  and 
air  draughts  to  which  pupils  are  so  much  exposed.  It  would  be  of 
much  service  in  properly  ventilating  school  rooms  were  open  fire- 
places in  more  general  use,  and  it  is  to  be  hoped  that  ai'chitects  will 
insist  on  the  introduction  of  these  in  the  future.     Insufficiency  of 


400  THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN. 

clothing  and  exposure  to  inclement  weather,  especially  if  obliged  to 
sit  in  wet  garments,  is  a  common  experience  among  children  of  the 
poor,  whose  parents  urge  their  attendance  at  school  under  these  con- 
ditions, that  they  may  be  relieved  of  their  care  at  home.  Children, 
on  the  contrary,  become  very  sensitive  from  wearing  too  much  cloth- 
ing, the  neglect  of  out-door  exercise,  and  confinement  in  overheated 
rooms.  Overheated  rooms  are,  moreover,  if  ventilation  is  attempted, 
dangerously  draughty.  Head  catarrhs  with  aural  complications  are 
as  frequent  from  these  causes  as  from  any  before  mentioned.  Neg- 
lect of  the  physical  condition  of  school  children  would  seem  not  a  less 
culpable  oversight  than  a  disregard  of  intellectual  training. 

Temperature  of  the  school  room.  The  temperature  of  the  school 
room  should  be  kept  at  about  68°  or  70°  Fahrenheit,  as  indicated  by 
the  thermometer;  it  should  not  be  regulated  by  the  sensitiveness  of 
any  individual,  such  a  test  being  by  no  means  reliable  for'  this  pur- 
pose. The  necessity  for  the  renewal  of  fresh  air  for  ventilating  pur- 
poses must  be  determined  by  the  season  of  the  year,  the  size  of  the 
room,  and  the  number  of  pupils  present;  when  the  doors  and  win- 
dows are  thrown  open  for  this  purpose,  the  children  should  be  required 
to  leave  their  seats  and  walk  about  in  order  to  avoid  any  ill  effects 
from  draughts.  Children  should  be  protected,  if  possible,  from  ex- 
posure to  currents  of  air  after  exercising;  nor  should  they  stand  or 
sit  while  •'' cooling  off,"  but  move  about  quietly  and  resume  any 
wraps  that  have  been  laid  aside.  The  air  of  crowded  halls  or  lecture 
rooms,  especially  when  illuminating  gas  is  used,  soon  becomes  much 
vitiated,  and,  by  depriving  the  system  of  its  natural  powers  of  resist- 
ance, favors  the  invasion  of  colds. 

Some  of  the  school-houses  of  cities  are  necessarily  erected  in  the 
noisy  districts,  for  they  must  be  near  to  the  homes  of  the  pupils. 
The  unremitting  din  of  street  noises  is  undoubtedly  distracting,  es- 
pecially when  the  doors  and  windows  have  to  be  kept  open ;  such 
sounds  fatigue  the  mind,  however  familiar  they  may  be.  The  dis- 
comfort from  this  cause  should  be  considered  in  selecting  the  site  for 
a  building,  and  the  construction  of  pavements  which  allow  of  the 
noiseless  passage  of  vehicles  in  the  immediate  neighborhood  would  be 
advisable. 

Whilst  our  system  of  school  hygienics  is  by  no  means  perfect,  the 
home  sanitation  of  children  is  also  deplorably  faulty  ;  when  these  shall 
have  been  corrected,  much  physical  suffering  will  be  prevented  and 
many  of  the  complaints  under  consideration  avoided. 

For  more  particular  information  on  this  subject,  the   reader  may 


THE    EDUCATION    OF    DEAF    SCHuOL    CHILDREN.  401 

consult  other  chapters  of  this  work  in  which  the  causes  above  men- 
tioned, and  others,  are  specially  discussed. 

CLASSIFICATION    OF    DEAF    CHILDREN. 

Acquired  deafness. — Conditions  favoring  early  deafness  are  not 
wanting;  indeed  causation  may  antedate  or  be  encountered  at  birth, 
since  at  this  period  the  drum  in  a  normal  state  contains  no  air,  but 
is  filled  with  loose  oedematous  connective  tissue,  which  slowly  disap- 
pears when  aeration  of  the  cavity  takes  place  with  the  establishment 
of  the  respiratory  act,  the  cries,  and  the  performance  of  deglutition 
by  the  infant.  "When  action  of  the  upper  respiratory  tract  is  defec- 
tive, as  it  may  thus  be  at  birth,  or,  soon  after,  by  head  catarrh  or  by 
aural  catarrh,  the  necessary  aerial  equilibrium  is  not  established,  and 
oscillations  of  the  transmitting  apparatus  cannot  take  place.  Under 
these  circumstances,  the  perceptive  function  lies  dormant  because  it 
cannot  be  aroused  to  normal  action. 

Congenital  deafness. — A  tendency  to  propagate  constitutional  dys- 
crasias  doubtlessly  exists  in  some  persons,  and  when  predisponents  to 
catarrh  are  active  ia  such  a  case,  hereditary  catarrh  may  give  rise  to 
disease  of  the  ear  at  the  earliest  period  of  life. 

Deafness  due  to  congenital  anomalies  of  the  auditory  apparatus. — 
These  are  supposed  to  be  traceable  to  some  perversion  of  development 
during  the  morphological  state.  The  hearing  organ  in  man  has  both 
an  intracranial  and  extracranial  origin,  one  centric  and  the  other 
peripheric.  From  the  auditory  vesicle  which  constitutes  the  centric 
is  evolved  the  nervous  or  perceptive  tract  of  the  ear,  while  the  first 
visceral  cleft  evolves  the  peripheric  or  outer  structures  comprising 
the  transmitting  apparatus,  namely,  the  Eustachian  tube,  the  drum, 
and  the  external  auditory  canal  and  auricle.  Now  during  the  embry- 
onic or  fetal  states,  any  interference  with  the  development  in  either 
of  these  regions  would  produce  defects  in  the  hearing  organ.  Evi- 
dence of  developmental  defects  is  not  always  obtainable,  and  where 
the  trouble  is  centric  the  diagnosis  cannot  be  made  in  the  very 
young,  for  obvious  reasons.  Evidences  of  peripheric  defects,  how- 
ever, are  by  no  means  rare  ;  these  consist,  for  the  most  part,  in 
either  defective  or  excessive  development  in  the  closure  of  the  first 
branchial  cleft,  the  most  common  form  of  which  is  fistula  auris  con- 
genita. The  presence  of  these  anomalies  is  very  likely  to  be 
overlooked.  In  the  following  typical  example  they  were  not  ob- 
served until  several  examinations  of  the  ear  had  been  made,  their 
existence  not  being    suspected  at    first  :  The    case   was  that   of  a 

child  of  eight  years  of  age.     She  was  thought  to  be  defective  in  in- 
26 


402  THE   EDUCATION   OF   DEAF    SCHOOL   CHILDREN. 

telligence  until  she  was  two  years  of  age,  since  she  did  not  learn  to 
talk  ;  but  she  grew  more  intelligent  in  appearance,  and  it  was  then 
found  that  she  was  deaf.  When  four  years  old,  some  person  under- 
took the  task  of  instructing  her  during  a  long  sea  voyage,  and  she 
learned  to  spell  and  pronounce  a  few  words.  When  five  years  old 
she  was  sent  to  the  public  schools  in  New  York,  and  had  made  con- 
siderable progress  up  to  the  time  when  she  was  brought  to  the  author. 
Examination  of  the  hearing  showed  that  she  could  not  understand 
conversation  in  any  tone  at  the  distance  of  a  few  feet ;  but  when  her 
name  was  spoken  in  a  sharp  tone  she  would  promptly  look  at  the 
speaker.  She  can  hear  the  voice  quite  distinctly  when  the  speaker  is 
only  a  few  inches  distant.  The  teacher,  for  some  reason,  requires 
her  to  sit  in  the  farthest  seat  from  her  desk.  A  minute  fistulous 
opening  is  to  be  seen  on  the  front  part  of  both  auricles,  from  which  a 
small  quantity  of  offensive  fluid  issues  spontaneously  at  times,  and 
usually  on  the  right  side,  when  the  parts  are  pressed  by  the  fingers. 
The  external  auditory  canals  are  of  the  normal  size,  but  the  drum- 
heads are  somewhat  defective  in  appearance,  the  membranes  being 
puckered  in  their  anterior  superior  quadrant. 

The  author  has  seen  a  very  considerable  number  of  these  cases  in 
adults,  where  hearing  was  always  defective,  and  although  generally 
unilateral,  it  is  probable  that  in  nearly  all  cases  some  degree  of  de- 
fectiveness exists  on  both  sides.  It  seems  probable  that,  where  cen- 
tric malformation  exists,  co-existent  mental  defects  are  liable  to  ob- 
tain, and  we  should,  therefore,  expect  to  find  imbecility  as  well  as 
deafness. 

The  existence  of  deafness  is  not  discovered  even  by  discerning  pa- 
rents during  the  first  few  weeks  of  infancy,  and  what  is  frequently  a. 
mere  suspicion  in  this  regard  at  the  sixth  month  may  not  become  a 
painful  reality  before  the  child  is  expected  to  talk,  and  then  the  slow- 
ness of  intellectual  development  may  not  be  properly  attributed  to 
defective  hearing.  Partial,  but  disqualifying,  deafness  is  thus  liable 
to  be  overlooked  until  school  education  is  attempted. 

The  detection  of  the  very  existence  of  hearing  defects,  it  may  be 
premised,  is  attended  with  difl&culty,  even  by  experts,  during  the  ear- 
liest period  of  infancy,  and  even  at  the  school  age  the  exact  degree  of 
disqualification  is  not  readily  determined  ;  it  is  with  the  view  of  af- 
fording some  aid  to  parents  and  teachers  in  this  regard  that  this  is 
written.  In  order  to  enhance  the  practical  value  of  the  views  ad- 
vanced, the  author  availed  himself  of  notes  that  have  been  taken  dur- 
ing an  extended  experience  in  the  examination  and  treatment  of  the 
aurally  defective. 


THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN.  403 

The  478  cases  of  children's  deafness  selected  as  illustrative,  are  from 
among  children  seen  in  private  and  infirmary  practice,  and  they  repre- 
sent almost  every  variety  of  disqualifying  deafness.  The  defective 
pupils  among  this  number  were  brought  from  both  hearing  and 
deaf-mute  schools.  A  considerable  number  of  these  constitute  a  class 
not  properly  provided,  for  in  either,  being  too  deaf  for  hearing  schools 
and  yet  not  deaf  enough  to  be  taught  as  deaf-mutes;  they  were,  there- 
fore, found  to  be  oscillating,  shuttle-cock  like,  between  the  two, 
liable  to  be  cast  forth  into  life  with  much  less  education  than  their 
intelligence  entitled  them  to  receive — usually  with  scarcely  intelligible 
articulate  speech. 

On  account  of  their  instructiveness,  there  have  been  included  in 
the  cases  above  selected  a  few  no  longer  strictly  of  the  school  age. 

The  cases  may  be  divided  into  two  groups  based  on  their  school 
status;  thus  371  were  attempting  to  retain  their  position  in  hearing 
schools,  whilst  the  others  were  either  so  deaf  as  to  be  excluded  or 
were  not  of  the  school  age. 

The  first  group  of  371  was  constituted  as  follows  :  74  were  between 
five  and  eight  years  of  age ;  200  were  between  eight  and  thirteen 
years  of  age  ;  97  were  over  thirteen  years  old.  As  to  sex,  199  wera 
females  and  172  were  males. 

The  causation  in  these  cases  could  be  traced,  in  the  majority  of  thes 
patients,  to  either  purulent  or  non-purulent  inflammation  of  the. 
middle  ear.     In  219  of  them  it  was  the  former,  in  124  the  latter. 

Usually  both  ears  were  similarly  affected  in  each  case,  but  where  a 
purulent  affection  existed  on  one  side  and  non-purulent  on  the  other,, 
the  case  was  classed  with  the  former.  In  the  non-purulent  cases,, 
both  ears  were  almost  without  exception  similarly  affected,  although 
the  left  ear  was  usually  the  worse  of  the  two. 

Belonging  to  either  one  or  the  other  of  the  above  varieties  were  10 
cases  where  the  ear  had  been  severely  boxed  or  pulled,  causing  rup- 
ture or  strain  of  the  drum-head,  and  consequent  deafness ;  33  cases 
where  cold  sea-water  had  passed  from  the  mouth  up  into  the  drum 
through  the  Eustachian  tube,  while  the  child  was  bathing  in  the 
ocean  ;  3  where  water  was  introduced  into  the  drum  while  sniffing  it 
up  into  the  nose,  or  in  using  the  nasal  douche.  In  31  cases  the  cause 
was  attributed  to  scarlet  fever,  in  17  to  measles,  in  5  to  diphtheria, 
in  4  to  whooping-cough,  in  1  to  mumps,  and  in  1  to  syphilis. 

The  external  auditory  canal  was  obstructed  in  a  number  of  in- 
stances, thus  interfering  with  the  entrance  of  sound  ;  in  52  cases  it 
was  by  wax,  in  7  by  foreign  bodies,  in  25  by  narrowing  of  its  walls  by 


404  THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN. 

inflammation.  Among  the  last-named  were  8  cases  where  the  canal 
was  ulcerated. 

The  drum-head  gave  evidence  of  defectiveness  of  the  transmitting 
mechanism  in  a  considerable  number  of  cases.  Thus,  in  30  there  was 
deformity  of  the  membrana  tympani  from  arrested  development ;  in 

27  cases  there  was  greater  or  less  destruction  of  the  transmitting 
mechanism  from  suppurative  inflammation  ;  a  polypoid  growth 
sprung  from  the  morbid  tissues  within  the  drum  in  14  cases,  and  the 
inflammation  extended  from  the  drum  to  the  pneumatic  cells  of  the 
mastoid  in  8  cases. 

It  is  noteworthy  that  defective  teeth  were  present  in  nearly  every 
case,  and  in  189  of  them  the  teeth  were  specially  bad.  Head-catarrh 
and  enlarged  tonsils  were  present  in  the  greater  number,  and  in  13 
cases  either  the  nasal  passages  were  so  much  obstructed,  or  the  teeth 
so  malformed,  that  mouth  breathing  was  habitual. 

The  affections  thus  far  mentioned  are  those  which  interfere  with 
the  passage  of  sound  to  the  middle  ear  and  its  transmission  to  the 
inner  ear,  but  the  deeper  parts  containing  the  distribution  of  the 
auditory  nerve  may,  in  the  more  severe  cases  of  ear-disease  occurring 
from  scarlet  fever,  diphtheria,  etc.,  be  attacked  at  the  same  time.     In 

28  of  these  cases,  it  may  be  incidentally  stated,  either  tumors,  or  ab- 
scesses, or  wounds  of  the  auricle  from  piercing  for  rings,  were 
observed.  Distress  from  the  autophonia  of  ear-disease,  the  autopho- 
nous  perception  of  voice  and  sounds  arising  from  the  performance  of 
physiological  functions  of  the  circulation,  respiration,  and  swallowing, 
were  present  in  41  cases,  and  dysacousma  was  present  in  1.  Otalgia 
was  experienced  by  28,  neuralgia  about  the  ear  by  36,  ear-cough  by 
10,  epilepsy  by  1,  vertiginous  symptoms  by  18,  chorea  by  2,  and 
various  other  reflex  phenomena  by  17. 

In  respect  to  the  degrees  of  deafness,  113  were  almost  totally  deaf, 
while  the  remaining  258  were  all  of  them  incapacitated  in  some  de- 
gree from  receiving  instruction  at  school  along  with  good-hearing 
scholars.  Thus,  some  of  them  had  to  leave  school  entirely  ;  some 
had  offensive  discharges  from  the  ear  or  severe  pains  in  the  organ. 
Many  of  them,  besides  being  backward  from  inability  to  hear  the 
teacher,  labored  under  the  disadvantage  of  being  regarded  as  ''  stu. 
pid,"  and  were  punished  for  inattention.  In  a  considerable  number, 
this  punishment  was  the  more  reprehensible  because  of  the  almost 
total  deafness  which  the  teachers  had  taken  no  measures  to  discover, 
but  had  placed  them  upon  back  seats  where  they  could  hear  nothing, 
and  were  punished  accordingly. 

Of  the  second  group,  consisting  of   107  cases,  91  were  so-called 


THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN.  405 

deaf-mutes,  and  of  these  the  ages  and  sex  were  as  follows:  47  were 
males,  44  females;  45  were  under  five  years  of  age;  36  between  five 
and  eight  years;  13  between  eight  and  thirteen  years;  whilst  7  were 
over  thirteen  years  of  age. 

The  16  remaining  cases  composing  the  second  group  were 
such  as  were  suffering  from  defective  articulation,  speech,  mental 
development,  etc.,  consequent,  for  the  most  part,  to  defective  hear- 
ing. Eight  of  these  patients  were  males,  and  8  females.  Six  of 
the  males  and  4  of  the  females  were  over  nineteen  years  of  age, 
the  remainder  being  children  under  ten  years. 

It  was  observed  that  in  the  greater  number  of  all  of  the  cases  above 
■presented,  the  cause  of  aural  defectiveness  was  attributable  to  some 
inflammatory  affection  of  the  hearing  organ.  Changes  due  to  chronic 
catarrh  of  the  middle  ear  were  observed  in  very  many,  as  also  were 
those  consequent  to  chronic  purulent  otitis  media.  Marked  arrest  of 
development,  as  shown  by  the  appearance  of  the  drum-head,  was 
present  in  numerous  instances.  In  4  cases  the  deafness  was  as- 
serted to  be  of  hereditary  origin,  and  two  children  (deaf-mutes)  were 
suffering  from  the  effects  of  congenital  syphilis.  Whooping-cough 
was  said  to  have  caused  the  aural  disease  in  2  cases,  diphtheria 
in  3,  measles  in  2,  scarlet  fever  in  8,  and  typhoid  fever  in  2 
cases.  Cerebral  meningitis,  occurring  in  connection  with  children's 
diseases,  contributed  largely  to  the  list  of  alleged  causative  influences. 
Meningeal  inflammation  is  usually  meant  when  pachymeningitis, 
cerebro-spinal  meningitis,  brain  fever,  cerebral  meningitis,  convulsions, 
fits,  and  the  like,  are  mentioned  by  writers  in  this  connection.  It  is 
impossible,  however,  to  accept  the  assertion  of  the  parents  or  of  the 
patients  themselves,  in  regard  to  the  cause  of  their  malady,  in  every 
instance,  and  this  is  especially  applicable  to  the  last-mentioned  dis- 
ease. Sometimes  the  symptoms  of  irritation  of  the  stomach  are  so 
marked  in  meningitis  that  the  case  has  been  erroneously  regarded  as 
one  of  "gastric  fever."  On  the  other  hand,  it  is  not  by  any  means 
uncommon  to  mistake  an  attack  of  acute  inflammation  of  the 
middle  ear  for  one  of  so-called  "brain  fever. '^  In  some  of  the  cases 
above  enumerated,  especially  among  the  deaf-mutes,  the  deafness  was 
claimed  to  be  congenital.  Experience,  and  a  more  particular  study  of 
the  subject,  will  often  show  that,  in  quite  a  number  of  these  supposed 
deaf-born  children,  the  disability  should  be  assigned  to  extra-uterine 
causation. 

Thus  cerebral  meningitis  affecting  the  nerve  of  hearing,  and  sup- 
purative inflammation  of  the  drum  of  the  ear  affecting  the  trans- 
mitting mechanism,   consecutive   to  children's  diseases,   as  scarlet 


406  THE    EDUCATION   OF   DEAF    SCHOOL    CHILDREN. 

fever,  measles,  and  diphtheria,  are  frequently  met  with  at  the  period 
in  life  when  children  are  learning  to  talk,  and  the  more  carefully 
these  patients  are  examined  in  this  regard,  the  more  frequently  will 
it  be  found  that  deafness  was  first  discovered  to  exist  subsequently 
to  some  attack  of  this  kind.  In  eliciting  from  parents  the  history 
of  these  cases,  one  should  not  place  too  much  value  on  alleged  in- 
jury to  the  ears  from  falls  and  blows  on  the  head,  which  are  often 
advanced  as  causes. 

In  nearly  all  of  these  patients  there  existed  catarrh  of  the  upper 
air-passages,  decayed  teeth,  etc. 

In  regard  to  their  aural  defectiveness,  many  of  them  were  found  to 
hear  well  enough  to  be  taught  aurally  by  the  aid  of  a  conversation- 
tube,  or  by  using  the  voice  close  to  the  child's  ear  in  teaching;  two  of 
them,  although  totally  deaf,  attended  school  along  with  hearing 
pupils;  six  of  them  retained  speech  after  losing  their  hearing,  and 
this  without  the  aid  of  a  teacher,  and  one  of  this  number,  a  girl, 
continued  to  use  the  English  cockney  accent  which  she  had  acquired 
before  becoming  deaf;  in  nineteen  cases  the  children  were  losing  the 
speech  they  haft  acquired  before  becoming  deaf,  or  were  very  defective 
in  this  regard  from  neglect  to  teach  them.  The  younger  children 
composing  this  last-mentioned  class  were  nearly  all  of  them  back- 
ward in  learning  to  talk;  one  of  them  did  not  acquire  speech  until 
his  good-hearing  brother  became  old  enough  to  converse  with  him, 
and  another  did  not  talk  until  five  years  of  age.  In  numerous  in- 
stances the  patients  had  never  learned  to  talk,  and  a  considerable 
number  of  these  were  considered  mentally  defective,  solely  on  account 
of  this  defect,  by  their  parents  or  teachers.  In  two  cases  it  was  noted 
that  the  impact  of  sounds  was  painful  (dysacousma). 

The  defective  children  believed  to  be  greatly  neglected  in  regard  to 
their  education  may,  for  convenience  in  this  connection,  be  arranged 
into  three  classes,  namely: 

1.  Children  defective  in  one  or  both  ears,  and  requiring  close  prox- 
imity and  distinct  utterance  when  taught.  Of  these,  deafness  in  both 
ears  requires  seating  on  front  row  of  benches,  but  when  only  one  ear 
is  affected,  the  normal  ear  must  be  toward  the  teacher's  desk. 

2.  Children  vuy  deaf,  who  cannot  distinguish  ordinary  conversa- 
tion in  either  eat  when  more  than  a  few  inches  from  the  speaker  or 
unless  the  conveisation  tube,  otacoustic  fan,  or  other  aid  to  hearing 
be  employed. 

3.  The  totally  deaf,  in  whom  the  auditory  apparatus  of  the  middle 
ear  cannot  be  made  available.  This  class  admits  of  division  into  two 
subdivisions,  viz. :  a,  those  having  learned  to  talk  previous  to  losing 


THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN.  407 

their  hearing,  and  b,  those  born  too  deaf  to  ever  have  naturally  ac- 
quired speech,  commonly  known  as  congenital  deaf-mutes. 

The  confusion  and  consequent  injustice  to  deaf  pupils  arising  from 
neglect  to  classify  them  properly.  It  will  be  admitted,  if  the  figures 
above  given  concerning  the  deaf  be  approximately  correct  even,  and 
it  is  believed  as  further  examinations  are  made  they  will  be  found  not 
to  be  in  excess  of  the  correct  number,  that,  in  so  far  as  educational 
objects  are  concerned,  we  cannot  separate  pupils  into  two  great  classes, 
one  of  ivhich  can  hear  ivell  and  the  other  not  at  all,  by  au  arbitrary  or 
sudden  line  of  demarcation,  inasmuch  as  the  hearing  disabilities  of 
children  consist  in  all  degrees  of  deafness,  ranging  between  slight  de- 
fects and  absolute  incapacity. 

It  would  seem  necessary,  therefore,  that  some  practical  scheme  for 
the  classification  of  the  deaf  should  be  made  which  would  not  exclude 
any  from  the  schools.  Under  the  present  arrangement,  the  only  class 
of  defectives  provided  for  has  been  the  so-called  deaf-mute  class,  which 
leaves  out  of  consideration  entirely  a  large  number  of  partially  and 
Tery  deaf  pupils,  occupying,  so  to  speak,  intermediate  ground  between, 
totally  deaf  and  normal  hearing  persons.  This  arrangement  abso- 
lutely places  a  certain  nnmber  of  pupils  in  a  worse  condition  than  if 
entirely  deprived  of  their  hearing  sense,  and  in  consequence  a  great 
many  of  them  find  their  way  into  deaf-mute  schools.  Thus  it  will  be 
seen  that  the  classification  in  both  the  day  and  deaf-mute  schools  is 
defective,  and  that  in  any  attempt  to  improve  matters  we  are  at  once 
met  by  a  most  complexing  dilemma;  thus,  owing  to  the  long  continued 
practice  of  forcing  all  deaf  pupils  into  either  a  totally  deaf  or  good 
hearing  class,  we  find  that  some  of  the  former  and  all  of  the  very  deaf 
and  partially  deaf  have  been  relegated  to  the  hearing  schools,  while 
other  very  deaf  persons  are  classified  with  the  totally  deaf  and  taught 
as  deaf-mutes. 

It  will  be  well  to  define  the  different  degrees  of  aural  disability  which 
incapacitate  the  pupil,  to  a  greater  or  less  extent,  from  receiving  in- 
struction in  the  ordinary  manner,  in  order  that  it  may  be  ascertained 
what  special  means  of  instruction  are  necessary. 

Normal  hearing  may  be  said  to  consist  in  the  mental  perception  of 
sound  that  has  been  transmitted  through  the  unimpaired  medium  of 
both  ears.  Without  binaural  hearing  the  aquisition  of  knowledge  by 
the  ordinary  methods  of  instruction  becomes  difficult  proportionately 
to  the  degree  of  aural  impairment.  Hearing  with  both  ears  thus  en- 
ables the  pupil  to  quickly  determine  the  direction  from  which  sound 
proceeds,  and  it  also  enables  him  to  promptly  recognize  the  finer  shad- 
ing in  the  pronunciation  of  words.     When,  therefore,  a  pupil  is  ob- 


408  THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN. 

served  to  be  backward  in  his  studies,  the  teacher  slionld,  before  at- 
tributing his  want  of  success  to  mental  defects,  inquire  if  he  hears 
well.  It  would  be  by  no  means  a  wise  procedure  to  classify  every  de- 
parture from  the  normal  standard  among  those  who  require  particular 
care  on  account  of  their  defectiveness,  for  a  pupil  may  progress  very 
fairly  in  his  studies  when  the  hearing  of  only  one  ear  remains  or  when 
he  has  very  considerable  defects  in  both  ears;  yet  snch  pupils  will  be 
very  much  aided  by  the  recognition  of  their  disabilities. 

The  acquisition  of  language  may  be  said  to  consist  in  correctly 
hearing  the  words  and  sentences  of  which  language  is  composed,  and 
in  the  persistent  repetition  of  the  same  until  memorized.  Children, 
therefore,  require  good  ears  and  long  practice  in  the  imitation  of  the 
voice  of  their  instructors  before  they  become  masters  of  spoken'lan- 
guage.  It  should  be  kept  in  mind  here  that  a  slight  degree  of  deaf- 
ness may  be  sufficient  to  hinder  the  child  in  the  first  steps  that  he 
takes  in  learning  to  talk — and  these  first  steps  are,  probably,  much 
more  immature  than  they  are  usually  thought  to  be,  as  the  infant  is 
at  first,  probably,  unconscious  of  most  sounds,  the  perceptive  faculties 
of  the  ear  not  being  taxed  beyond  the  requirements  of  the  mental 
faculties. 

It  is  very  difficult  to  discover  defectiveness  of  hearing  before  the 
child  is  one  year  old;  owing  to  this  fact,  the  child  maybe  "stone 
deaf  "  for  a  considerable  time  before  the  discovery  is  made.  Even  a 
slight  defect  in  hearing  is  a  detriment  to  the  infant,  for  his  education, 
begins  as  soon  as  the  slightest  attention  to  sound  is  given. 

The  child,  in  this  process  of  acquiring  knowledge,  repeats  words  as 
they  are  heard;  if  it  hears  them  incorrectly,  a  faulty  enunciation  is 
acquired;  thus  every  one  has  observed  in  his  own  experience  how 
unintelligible  the  language  of  partially  deaf  children  is,  how  slow  they 
are  in  learning  to  talk.  The  flexibility  of  the  voice  is  naturally  very 
great,  and  uninterrupted  practice  increases  its  fluency  from  day  to 
day;  the  young  learner,  relying  on  his  imitative  faculties  rather  than 
his  own  judgment,  readily  adopts  the  accent  of  his  teachers  and  asso- 
ciates, and  in  this  manner  he  acquires  the  dialect  of  the  locality  in 
which  he  lives. 

The  hearing  that  remains  after  injury  of  the  ear-drum.  Often 
after  great  impairment  or  destruction  of  the  transmitting  apparatus 
of  the  ear-drums,  a  very  efficient  passage  of  sound  to  the  auditory 
nerve  remains;  but  as  this  becomes  more  and  more  difficult,  it  deteri- 
orates in  quality,  especially  for  long  distances,  until  finally  its  rendi- 
tion in  the  very  hard-of- hearing  becomes  so  crude  and  indefinite  that 
interpretation  by  the  perceptive  tract  is  difficult,  or  even  impossible. 


THE    EDUCATION   OF   DEAF  SCHOOL    CHILDREN.  409 

Now,  when  sound  ceases  to  be  transmitted  in  this  manner,  hearing 
may  take  place  by  means  of  the  passage  of  sound  up  through  the 
tissues  of  the  head  to  the  perceptive  tract  as  propagated  by  means  of 
the  otacoustic  fan  placed  on  the  teeth,  or  the  conversation  tube  placed 
in  the  mouth.  In  tlie  former  instance,  sound  passes  more  directly 
along  bone  structure  from  the  teeth,  while  in  the  latter  it  ascends  to 
the  vault  of  the  resonating  chamber  at  the  top  of  the  pharynx  and 
thence  up  through  the  tissues  of  the  head.  Voice-sounds  imparted  to 
a  pupil  in  the  manner  just  mentioned  are  of  very  great  value  in  certain 
cases,  because  of  their  tones  being  natural,  and  the  pupil's  own  voice 
is  even  more  effective  in  this  respect,  since  it  is  propagated  upward 
with  much  energy  by  his  own  vocal  efforts  against  the  moist  and 
highly  receptive  pharyngeal  vault. 

Incapacitating  deafness.  All  degrees  of  deafness  may  be  said  to 
impair  the  learning  capacity  of  a  pupil,  but  in  establishing  a  standard 
of  impairment  which  shall  consign  a  pupil  to  exclusion  from  his 
better  hearing  fellows  for  instruction,  it  would  be  well  to  select  for 
special  methods  those  who  are  unable  to  understand  what  is  said  to 
them  in  the  ordinary  tone  of  voice  when  five  feet  away  from  the 
speaker.  Such  a  rule,  however,  must  necessarily  be  applied  with  dis- 
crimination; there  must  be,  in  other  words,  a  flexible  standard,  for 
some  defective,  but  well  advanced,  pupils,  by  reason  of  their  natural 
quickness,  will,  without  being  a  hindrance,  do  much  better  when 
subjected  to  the  emulative  influences  of  good  hearing  children. 

THE    TREATMENT,    MANAGEMENT,    AND    EDUCATION    OF    DEAF    PUPILS. 

The  question  of  the  accountability  of  the  public  schools  for  the 
physical  as  well  as  intellectual  improvement  of  children  is,  to  some 
extent,  a  debatable  one;  it  is  a  matter  that  seems  to  depend,  in  many 
instances,  on  the  sense  of  duty  that  inspires  the  management  of  par- 
ticular schools,  inasmuch  as  the  recommendations  for  the  guidance  of 
teachers  concerning  hygienics  are  entirely  inadequate.  The  writer 
believes  that,  as  regards  the  more  unfortunate  children  of  the  very 
poor — the  unwashed  of  both  body  and  raiment — no  inconsiderable 
number  of  them  would  be  more  benefited  by  personal  hygiene  than 
by  mental  training;  at  least  the  two  should  go  hand  in  hand  in  every 
instance,  for  mens  sana  in  corpore  sano. 

The  chief  object  of  the  public  school  system  being  the  elevation  of 
the  entire  population,  thus  placing  them  beyond  the  boundary  of 
charitable  support,  their  bodily  well-being  must  be  assured  by  influ- 
ences brought  to  bear  during  the  formative  period  of  life. 

In  their  examinations,  deaf  children,  notwithstanding  their  defects. 


410  THE    EDUCATION    OF  DEAF   SCHOOL  CHILDREN. 

may  come  forward  well  prepared;  but  if  examined  in  a  hasty  or 
impatient  manner,  the  teacher's  questions  are  liable  not  to  be  heard 
well  enough  to  elicit  correct  answers,  and  they  are  thus  unable  to 
secure  a  promotion  which  their  preparation  has  Justly  entitled  them 
to  receive. 

The  surroundings  of  these  children  are  in  every  way  discouraging; 
they  are  disheartened  both  at  home  and  at  school,  subjected,  as  they 
are,  to  the  jeers,  ridicule,  and  mockery  of  their  companions,  and  to 
the  punishment  of  parents  and  teachers  for  seeming  inattention  and 
dulness. 

Their  inability  to  hear  much  of  what  is  said  to  them,  the  difficulty 
they  experience  in  the  correct  pronunciation  of  words  when  the  vocal 
organs  are  deficient,  and  the  dismay  occasioned  by  autophonous  hear- 
ing and  noises  in  the  head,  either  singly  or  combined,  are  sufficient 
to  entirely  discourage  these  sufferers.  That  they  become  distrustful, 
deceitful,  and  vicious  in  character  is  to  be  expected. 

When  we  come  to  consider  what  effect  these  various  experiences 
must  have  on  the  minds  of  children,  our  sympathies  should  be  enlisted 
in  their  behalf  to  the  last  degree,  and  our  patience  should  be  without 
limit;  in  a  word,  when  no  apparent  cause  for  a  child's  dulness  of  action 
is  known  to  exist,  let  there  be  made  a  thorough  investigation  into  the 
condition  of  the  acoustic  organs  before  necessarily  regarding  it  as  a 
dunce  or  feeble-minded. 

In  the  treatment  or  education  of  deaf  children,  it  is  well  to  keep  in 
mind  the  fact  that  defectiveness  is  not  always  absolute,  and  may, 
therefore,  be  amenable  to  treatment  on  the  one  hand,  while  not  con- 
stituting an  insuperable  barrier  to  aural  instruction  on  the  other. 

It  would  seem  that  the  neglect  of  deaf-born  children,  in  the  lower 
order  of  social  life,  much  more  frequently  results  in  dumbness  than 
would  occur  if  more  pains  were  taken  in  their  education;  indeed, 
where  the  offspring  of  deaf-mutes  are  constantly  surrounded  by  deaf- 
mutes,  holding  converse  with  each  other  by  signs  only,  it  would 
be  strange  if  they  should  learn  to  talk  unless  possessed  of  good 
hearing  and  allowed  to  associate  with  speaking  persons.  If  children 
with  defective  hearing  organs  have  but  little,  if  any,  opportunity  to 
employ  them,  it  is  probable  that  continuous  disuse  of  the  sensory 
tract  would  finally  lead  to  its  deterioration.  A  child  brought  up 
under  favorable  conditions  in  this  respect  would  acquire  the  use  of 
the  voice  with  difficulty,  if  at  all,  since  even  where  normal  hearing 
exists  and  favorable  opportunities  are  afforded  for  learning,  it  is  only 
after  long  and  patient  practice  that  intelligible  speech  is  acquired. 

The  examination  of  pupils  in  the  public  schools  with  a  view  of  de- 


THE   EDUCATION   OF  DEAF    SCHOOL   CHILDREN.  411 

iermining  thei?'  hearing  potoer.  It  will  not  be  denied  that  these  disa- 
bilities among  pupils  should  be  known  to  teachers  in  order  that 
instruction  may  be  made  more  successful,  and  it  therefore  becomes 
important  to  adopt  some  plan  for  correctly  determining  the  hearing 
power  of  all  school  children,  so  that  where  any  defect  exists  pupils 
may  be  placed  under  the  best  possible  advantages.  While  teachers 
are  known  to  often  fail  to  discern  marked  departures  from  the  nor- 
mal standard,  and  children  themselves  cannot  always  give  reliable  in- 
formation, yet  much  could  be  accomplished  by  principals  and  teachers 
were  they  assisted  at  the  start  by  an  expert  in  such  matters,  especially 
so  far  as  the  majority  of  pupils  are  concerned  ;  but  where  it  becomes 
important  to  ascertain  the  exact  state  of  the  transmitting  apparatus 
of  the  ear,  and  the  condition  of  the  nerve-tract  connected  with  audi- 
tion, an  expert  examination  would  be  required. 

It  would  be  well  were  it  a  requirement  that  the  pupils  of  the  public 
schools  should  be  examined  at  the  beginning  of  each  session  with  a 
view  to  ascertain  what  number  were  too  deaf  to  receive  instruction 
in  the  ordinary  manner  and  what  number,  having  slight  defects, 
would  get  on  better  if  seated  properly  in  the  school  room. 

Method  of  testing  the  hearing  power  of  pupils.  In  conducting  ex- 
aminations, it  will  be  foijnd  that  the  voice  of  the  person  with  which 
the  children  are  familiar  in  learning,  is  the  best  test,  and,  indeed,  it 
is  the  only  sound  '  that  need  be  used  ;  sounds  like  the  ticking  of  a 
watch,  for  example,  need  not  be  employed,  as  the  ability  to  hear 
them  is  not  significant  as  regards  the  pupil's  hearing  power  for  sounds 
used  in  teaching." 

The  sentences  selected  for  tests  should  be  intelligible  to  the  under- 
standing of  the  pupils,  and  yet  not  altogether  familiar  ones,  such  as 
■*'  What's  your  name  ?  "  and  the  like,  and  some  of  the  words  ought  to 
•contain  the  hissing  sounds,  others  the  guttural,  as  ^'m,"  "n,"  "g,'* 
us  these  are  heard  with  the  greatest  difficulty.  Unless  the  sentences 
made  use  of  are  frequently  changed,  the  pupils  may  become  familiar 
with  some  of  them  and  thus  comprehend  their  import  without  hear- 
ing them  distinctly. 

'The  audiometer  arranged  by  Prof,  Graham  Bell,  may  be  found  useful 
"wrhere  more  delicate  tests  are  required,  and  its  introduction  will  very  much 
facilitate  the  work  of  classification  when  used  by  an  intelligent  and  trained 
■examiner, 

*  The  diflSculties  in  the  way  of  establishing  a  uniform  standard  for  the  voice 
test  are  well-nigh  insurmountable,  inasmuch  as  no  two  persons  possess  voices 
of  equal  quality  ;  it  is  thought  best,  therefore,  for  the  teacher  of  each  class  to 
examine  his  own  pupils,  employing  for  this  purpose  the  tone  of  voice  usual 
in  teaching. 


412  THE    EDUCAIION    OF    DEAF    SCHOOL    CHILDREN. 

During  the  examination  the  pupil  should  be  placed  about  twelve 
feet  from  the  examiner  and  should  close  his  eyes  to  prevent  lip  read- 
ing ;  an  assistant  may  then  stop  one  of  the  pupil's  ears  by  the  pres" 
sure  of  his  finger  while  the  other  is  being  tested.  The  examiner  can 
now  ascertain  the  hearing  power  by  raising  or  lowering  his  voice  as 
required. 

In  every  instance  where  the  sense  of  hearing  is  found  to  be  defec- 
tive, some  record  of  the  fact  would  be  found  serviceable  for  future 
usCi  It  may  be  well  to  remark  in  this  connection  that  the  acoustic 
qualities  of  the  room  in  which  an  examination  is  held  should  be 
taken  into  account — whether  it  be  a  largp  or  a  small  room,  whether 
containing  many  persons,  draperies,  etc.,  or  comparatively  empty, 
and,  finally,  whether  any  open  doors  or  windows  admit  sounds  from 
without.  The  age  and  the  mental  development  of  the  pupil  are  also 
factors  of  importance,  an  uncultivated  mind  being  slow  in  compre- 
hension. 

The  separate  education  of  jnipils  whose  impaired  sense  of  hearing 
debars  them  from  the  benefits  of  education  by  ordinary  methods, 
from  the  investigation  that  has  been  made  concerning  their  capacity 
to  acquire  knowledge,  would  seem  to  be  a  necessity.  The  claims  of 
the  deaf-mute  have  been  long  since  recognized,  and  his  wants  in  great 
measure  provided  for;  it  remains  now  to  recommend  measures  for  a 
neglected  class  of  equal  numbers,  whose  requirements  are  no  less 
urgent. 

The  writer  will  not,  in  this  connection,  essay  to  suggest  any 
matured  scheme  for  the  special  instruction  of  those  who  are  not  en- 
tirely beyond  the  reach  of  vocal  methods,  but  who  are  yet  too  deaf 
to  be  taught  with  good  hearing  pupils,  without  interfering  with  their 
instruction;  the  attempt  would  carry  him  beyond  the  scope  of  this 
chapter.  Such  a  scheme  will  require  for  its  successful  development 
the  time  and  labor  of  experienced  teachers,  and  even  under  the  most 
favorable  circumstances  the  progress  of  any  plan  will  necessarily  be 
slow.  The  author  will,  however,  venture  to  offer  some  suggestions 
in  the  matter,  hoping  that,  inasmuch  as  his  views  have  been  derived 
from  a  very  considerable  experience  in  the  observation  of  aural 
defects,  the  advice  given  from  an  otologist's  standpoint  may  not  be 
without  value. 

Disposition  of  deaf  pupils  iji  the  school-room.  Any  pupil  found  to 
hear  the  ordinary  voice  of  the  teacher  with  difficulty  should  occupy 
a  seat  near  him. 

When  hearing  is  good  in  one  ear  only,  the  child  will  hear  to  the 


THE    EDUCATION   OF   DEAF    SCHOOL   CHILDREN.  413 

best  advantage  if  seated  rather  to  one  side,  so  that  the  good  ear  will 
be  toward  the  teacher. 

Pupils  whose  defective  sense  of  hearing  prevents  them  from  re- 
ceiving scarcely  any  instruction  by  the  usual  vocal  method  should  be, 
if  possible,  separated  from  the  good  hearing,  and  taught  by  special 
methods.  As  intimated  before,  children  who  cannot  understand  the 
teacher  at  the  distance  of  five  feet,  when  addressed  in  the  ordinary 
tone  of  voice,  are  not  only  an  obstruction  to  the  work  of  teaching 
other  pupils,  but  they  can  learn  but  little  themselves.  These  pupils, 
in  many  instances,  may  perhaps  remain  very  deaf  only  a  short  time; 
they  may  be  entirely  cured  by  treatment;  special  instruction  would 
then,  in  these  cases,  be  regarded  as  tentative  only,  for  when  improve- 
ment takes  place  their  advancement  will  be  more  rapid  among  pupils 
whose  hearing  is  good. 

When  it  is  found  that  children  are  too  deaf  to  make  any  progress 
or,  from  an  increase  of  deafness,  it  is  unmistakably  manifest  that  they 
cannot  be  instructed  by  vocal  methods,  they  may  be  relegated  to  a 
department  where  deaf-mutes  alone  are  taught. 

It  is,  of  course,  important  to  discover  the  existence  of  mentally 
feeble  scholars  since  these  are  often  incapable  of  making  scarcely 
any  advance,  besides  being  a  hindrance  to  others. 

The  importance  of  early  training  for  deaf  children. — Too  much 
stress  can  scarcely  be  laid  on  the  value  of  results  obtainable  in  this 
way  if  early  made,  since  the  perceptive  power  may  be  much  quickened 
by  training  in  many  instances,  even  where  the  middle  ear  apparatus  is 
defective.  It  would  appear  to  be  on  the  development  of  the  perceptive 
tract,  rather  than  on  any  change  in  the  transmitting  mechanism,  that 
mental  improvement  depends  in  the  very  deaf  who  are  taught  aurally. 
The  expert  himself  finds  it  no  easy  task  to  get  at  the  facts  in  cer- 
tain cases,  especially  in  young  children  who  have  already  been  in- 
structed as  totally  deaf,  since  they  soon  come  to  disregard  the  hearing 
sense  entirely,  and  it  remains  to  be  determined  in  such  cases  how 
much  the  auditory  nerve  has  deteriorated  from  disuse.  The  pro- 
fessed indifference  to  hearing  should  never  prevent  some  attempts 
being  made  at  instruction  through  the  hearing  organs,  since  a  sur- 
prising amount  of  hearing  may  thus  be  found  to  exist.  How  many 
children  one  meets  with  who  are  backward  in  learning  to  talk,  but 
finally,  on  getting  to  be  three  or  four  years  old,  gain  their  speech! 
Such  children  would  get  on  much  faster  in  many  instances,  it  is  believed, 
if  regarded  as  partially  deaf.  While  treating  such  children  profession- 
ally, the  writer  has  seen  beneficial  results  from  the  use  of  conversation- 
tubes,  or  the  employment  of  voice  at  close  range.     This  practice  can- 


414  THE    EDUCATION    OF   DEAF    SCHOOL   CHILDREN. 

not  be  too  early  commenced.  Good  results  have  been  recorded  in 
children  as  young  as  eighteen  months.  In  observing  these  cases,  one 
cannot  but  be  impressed  with  the  importance  of  normal  hearing  in 
the  ready  acquirement  of  speech,  and  that,  however  imperfect  the  hear- 
ing maybe,  it  has  its  uses  in  acquiring  language. 

If  a  medical  writer  might  venture  to  offer  a  suggestion  in  pedago- 
gics, the  author  would  urge  early  attention  to  home  instruction  for 
deaf  children.  Hearing  children  naturally  pick  up  their  earlier  edu- 
cation without  effort  from  parents  or  by  themselves,  but  deaf  children 
must  be  unremittingly  taught  at  close  range;  words  must  be  uttered 
directly  into  the  ear,  not  loudly,  but  distinctly.  Tubes  are  of  value 
in  conducting  sound  to  the  child's  ear  where  close  contact  of  the 
mouth  is  inconvenient,  and  the  child  should  be  encouraged  to  repeat 
its  own  words  through  the  tube  to  its  ears  so  as  to  compare  its  own 
voice  with  the  instructor's.  If  this  course  be  pursued  early  enough, 
the  writer  is  convinced  that  but  few  children  would  be  found  with 
out  any  hearing  sense,  and  many  who  have  considerable  hearing  likely 
to  be  lost  from  disuse,  would  gradually  be  improved. 

The  greatest  diflBculty  encountered  at  first  is  in  overcoming  inatten- 
tion on  the  part  of  deaf  children,  who  are  disposed  to  rely  on  the 
sense  of  vision,  since  it  offers  a  so  much  easier  method  of  conversing. 
Much  time  is,  doubtlessly,  lost,  from  neglect  to  insist  on  this  matter. 

The  dumbness  of  deaf  children  by  no  means  always  bears  a  constant 
relation  to  their  aural  defectiveness;  a  child  intellectually  bright,  with 
favorable  opportunities  for  learning,  will  make  much  more  rapid  ad- 
Tances  than  a  child  mentally  dull  and  neglected.  The  writer  has  met 
with  numerous  examples  where  totally  deaf  persons  obtained  an  excel- 
lent education  ia  private  hearing  schools;  they  had  been,  of  course^ 
attentive  and  quick  to  learn,  and  special  attention  had  been  given 
them  by  teachers. 

Teachers  of  deaf  pupils.  Many  teachers  have  already  fitted  them- 
selves for  this  work,  and  it  is  a  significant  fact  that  the  growing  de- 
mand for  better  instruction  of  the  deaf  has  enabled  them  to  find  ready 
employment  either  in  families  or  in  conducting  small  private  day- 
schools,  since  parents  are  willing  to  incur  this  extra  expense  rather 
than  place  their  children  in  deaf-mute  institutions.  Where  this  expense 
cannot  be  borne,  and  parents  are  unwilling  to  send  their  children  away 
from  home,  it  seems  that  to  exclude  them  from  the  advantages  of 
day-schools  is  to  disregard  their  rights. 

The  classification  of  the  future.  No  time  should  be  lost  in  taking 
steps  in  this  direction;  a  little  classification  must  necessarily  pave  thfr 
way  to  improvement  in  the  education  of  the  deaf  of  every  degree.  It 


THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN.  415- 

should  be  kept  in  mind,  however,  that,  in  a  certain  proportion  of  the 
partially  deaf,  the  defectiveness  is  transient  and  variable;  and  that  in 
some  of  the  more  difficult  cases  among  the  very  or  totally  deaf,  re- 
peated examination  will  have  to  be  made  when  any  doubt  as  to  the- 
diagnosis  remains. 

TOTAL    OR   ALMOST   TOTAL    DEAFNESS   AMONG   SCHOOL   CHILDREN. 

When  the  acoustic  organs  are  too  greatly  impaired  for  aural  in- 
struction, pupils  are  generally  designated  as  deaf-mutes.  They  are 
not  all  of  them,  however,  mute,  nor  can  they  all  be  instructed  equally 
well.  It  would  be  advisable,  therefore,  for  the  purposes  of  instruc- 
tion, to  divide  this  class  of  persons  into  two  principal  groups,  as 
follows  : 

1.  Those  who  have  never  learned  to  talk. 

2.  Those  who  have  learned  to  talk  before  becoming  deaf. 

Of  the  first-named  group  it  may  be  said  that  a  certain  number  are- 
congenitally  defective,  while  others  become  deaf  at  a  later  period  in 
childhood.  Notwithstanding  the  profound  deafness  of  these  children 
to  outward  sounds,  some  of  them  are  capable  of  learning  to  speak 
with  greater  or  less  distinctness,  the  perceptive  functions  of  hearing 
having  been  preserved  to  a  goodly  extent,  though  the  transmitting 
mechanism  has  sustained  almost  complete  impairment.  To  the  greater 
number  of  these  pupils  the  autophonous  voice,  which  remains 
to  them,  is  very  far  from  imparting  a  natural  impression  of  the 
voice  to  the  mind  ;  their  vocalization  is  notable  for  its  "■  muted  " 
cadence,  the  words  seeming  to  be  uttered  in  imitation  of  the  sounds 
transmitted  to  the  perverted  sense  of  hearing  from  their  own  vocal 
organs.  A  much  better  vocal  power  remains  when  children  have  pre- 
viously learned  to  talk  well  than  when  speech  has  not  been  so  ac- 
quired. Under  no  circumstances,  however,  will  the  voice  remain  un- 
changed ;  it  is  no  longer  flexible  and  pleasantly  modulated,  but  soon 
becomes  mechanical  and  harsh. 

The  second  group  of  deaf-mutes  includes  those  in  whom  there  is  an 
entire  absence  of  the  perceptive  function  of  hearing,  either  congeni- 
tally or  from  the  more  severe  diseases  which  deprive  the  auditory 
nerve  of  its  functions.  In  some  of  these  the  transmitting  mechanism 
of  the  middle  ear  may  not  be  greatly  impaired,  but  the  nerve  no 
longer  perceives  sensations  of  sound  from  any  source. 

Of  these,  the  congenitally  deaf  can  never,  the  author  is  inclined  to 
believe,  practicably  be  taught  to  speak  very  intelligibly,  for  they  can- 
not hear  any  sound  upon  which  the  mind  may  form  an  idea  as  to  the 
character  of  speech.     They,  however,  who  have  once  fairly  acquired. 


416  THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN. 

speech  may  retain  the  use  of  it  in  a  very  satisfactory  degree  after  be- 
coming deaf,  if  well  trained.  Very  young  children  who  have  only 
just  learned  to  talk  soon  lose  the  faculty,  and  it  is  very  difficult  for 
them  to  ever  learn  to  speak  well  again. 

In  a  certain  number  of  cases  of  deaf-mutism,  both  the  middle  and 
inner  ear  are  undoubtedly  affected  by  disease,  but  in  the  greater  num- 
ber of  cases  the  disability  seems  to  be  mainly  seated  in  one  of  these 
regions  only.  Where  the  functions  of  the  nerve  of  audition  have  not 
been  exercised,  in  consequence  of  early  impairment  of  the  mechanism 
on  which  transmission  of  sound  to  the  inner  ear  depends,  its  deterio- 
ration will  probably  ensue.  Owing  to  the  neglect  of  a  great  many  of 
these  children  at  home,  the  difficulties  in  the  way  of  their  education 
are  much  increased.  Although  the  number  of  pupils  who  will  be 
found  to  retain  some  sense  of  sound  perception  is  comparatively  small, 
yet  it  would  be  well  to  differentiate  between  these  and  the  pupils  who 
do  not,  for  the  former  possess  capabilities  for  learning  which  the  latter 
do  not  enjoy  ;  the  one  may  acquire  articulate  speech,  while  the  other 
may  be  advantageously  taught  the  sign  language  only. 

These  children,  in  the  larger  cities,  could  in  many  instances  be 
more  economically  taught  if  kept  under  home  influences  and  educated 
in  a  special  department  of  the  public  schools. 

THE  EDUCATION   OF   DEAF-MUTES   AND  THE   VERY   DEAF. 

a.  In  the  day-scJiools.  "While  attention  has  thus  been  drawn  to  the 
wants  of  the  partially  deaf,  strenuous  efforts  have  been  made  in  behalf 
of  the  deaf-mute  with  a  view  to  improving  his  educational  facilities. 
The  labors  of  Professor  Alexander  Graham  Bell  in  this  field  have 
been  notable,  and  besides  giving  much  personal  attention  to  the  work, 
his  contributions  to  the  literature  of  the  subject  have  been  numerous 
and  valuable.  But  while  the  writer  himself  has  mainly  had  in  view 
the  needs  of  the  partially  deaf,  yet  in  pursuing  this  interesting  subject 
from  his  own  point  of  view,  it  is  to  be  plainly  seen  that  from  a  peda- 
gogical standpoint  a  very  considerable  number  of  deaf-mutes,  so-called, 
may  be  more  advantageously  provided  for  in  the  public  day-schools 
than  otherwise. 

Day-schools  for  deaf  mutes  have  thus  been  established  in  the  United 
States  as  follows :  Horace  Mann  Day-school,  Boston,  in  1869  ;  Erie 
Day-school,  in  1874 ;  Chicago  Day-school,  in  1875  ;  Cincinnati  Day- 
school,  in  1875  ;  Portland,  Me.,  Day-school,  in  1876  ;  Khode  Island 
Day-school,  in  1877  ;  St.  Louis  Day-school,  in  1878 ;  Phonological 
School,  Milwaukee,  in  1878  ;  Oral  Branch  Pennsylvania  Institution, 
Philadelphia,   in   1881 ;    Scranton    Oral   School,  in  1883  ;   A,  Gra- 


THE    EDUCATION    OF    DEAF    SCHuOL    CHILDREN.  41T 

ham  BelFs  School,  Wasliington,  D.  C,  1883.  It  would  seem  that  the 
systems  of  deaf-mute  education  were  undergoing  a  transformation  at 
the  present  time,  since  hearing  defects  are  beginning  to  be  regarded 
as  constituting  a  factor  of  varying  importance,  no  longer  offering  an 
insurmountable  barrier,  in  a  great  number  of  instances,  to  an  educa- 
tion which  shall  enable  them  to  hold  converse  after  the  manner  of 
hearing  persons. 

This  leads  to  the  opinion  that  very  considerable  numbers  who 
are  at  present  being  educated  as  deaf-mutes  could  be  cared  for  in 
the  public  day-schools  along  with  the  very  deaf  who  are  at  present 
unprovided  for,  since  they  both  require  similar  methods  of  instruc- 
tion. 

Totally  and  very  deaf  children,  moreover,  require  taking  in  hand 
at  a  much  earlier  age  than  is  feasible  in  deaf  and  dumb  institutions; 
their  education  should,  in  fact,  begin  much  earlier  than  it  is  com- 
menced at  present;  they  should  be  placed  in  school  when  four  or  five 
years  old.  Children  who  have  lost  their  hearing  soon  after  acquiring 
speech  soon  forget  to  talk  unless  means  are  promptly  taken  to  keep 
them  in  practice.  The  same  rule  would  apply  with  equal  force  to 
the  congenitally  deaf,  since  valuable  time  is  lost  when  instruction  is 
neglected'during  the  impressionable  period  of  early  childhood.  It  be- 
comes a  necessity  in  respect  to  the  education  of  children  at  such  a 
tender  age  that  they  should  be  provided  for  in  schools  near  their 
homes,  an  entirely  practicable  matter,  fortunately,  in  large  cities  and 
towns,  and  even  in  sparsely  populated  districts,  according  to  the 
reasoning  of  Bell  in  his  "Memoir  upon  the  Formation  of  a  Deaf 
Variety  of  the  Human  Race." 

As  to  disassociating  very  young  children  from  home  influences,  the 
humane  impulses  of  parents  are  altogether  opposed  to  this;  the  writer 
has  often  witnessed  the  dismay  and  grief  of  parents  when  informed 
that  their  deaf  children  could  obtain  an  education  only  in  a  deaf-and- 
dumb  institution.  There  are,  perhaps,  a  few  families  who  prefer  to 
place  their  cliildren  away  from  home,  where  the  responsibilities  of 
support  and  training  will  be  assumed  by  others,  but  it  is  otherwise 
with  the  better  class  of  our  citizens,  who  desire  to  have  them  brought 
up  more  as  other  childi-en. 

b.  In  deaf-mute  institutions.  In  certain  institutions  an  increased 
interest  has  shown  itself  of  late  in  respect  to  the  very  considerable 
number  of  pupils  who  have  heretofore  been  treated  as  totally  deaf, 
but  who  are,  in  point  of  fact,  conscious  of  more  or  less  perception  of 
sound,  which  may  be  made  available  in  education.  The  results 
alleged  to  have  been  attained  by  means  of  aural  teaching  are  very 
27 


418  THE   EDUCATION   OF   DEAF    SCHOOL    CHILDREN. 

gratifying.  During  the  year  1877,  the  writer  yisited  some  deaf-mute 
institutions  with  a  view  to  discover  what  number  of  these  pupils  could 
hear  the  voice  by  means  of  a  conversation-tube  placed  in  the  mouth 
or  ear,  and  he  was  surprised  to  find  a  number  being  educated  as  deaf- 
mutes  with  whom  conversation  could  be  carried  on  orally  by  the 
employment  of  this  aid  to  hearing.  Kepeated  observations,  subse- 
quently made  by  teachers,  have  confirmed  the  above,  and  it  is  now 
believed  that,  of  all  the  pupils  in  deaf  and  dumb  institutions,  a  large 
number  could  be  educated  through  the  hearing  sense  by  the  aid  of 
speaking-tubes  and  otacoustic  fans,  and  that  a  small  number  hear  well 
enough  to  be  taught  by  the  unaided  voice.  In  the  Minnesota  institu- 
tion it  has  been  found  that  from  fifteen  to  twenty-five  per  cent  of  all 
the  pupils  received  can  be  taught  by  the  aural  method,  and  that  after 
being  instructed  for  a  time  many  could  hear  well  enough  at  the 
distance  of  ten  or  fifteen  feet  to  converse  when  elevated  voice  was 
used. 

The  disadvantages  arising  in  deaf-mute  institutions  from  the  want 
of  classification  show  themselves  in  many  ways;  thus,  where  no  useful 
perception  of  sound  has  ever  been  experienced  by  a  pupil,  as  in  most 
congenitally  deaf  persons,  or  where  mental  feebleness  exists,  there  is 
very  great  inaptitude  for  the  development  of  the  perceptive  func- 
tion, and  while  efforts  to  arouse  this  dormant  function  must  not 
be  too  early  abandoned  in  doubtful  cases,  yet  it  is  well  to  consider  how 
much  labor  can  be  profitably  devoted  to  the  task  of  teaching  such 
pupils  to  converse  orally.  The  discouraging  result  in  such  cases  has 
doubtlessly  been  the  means  of  establishing  a  preference  for  teaching 
the  sign  language,  since  in  overcrowded  deaf-mute  institutions  this 
method  has  the  advantage  of  being  inexpensive — an  important  item 
where  the  corps  of  instructors  is  small.  It  has  been  estimated  that 
about  ten  per  cent  of  deaf-mute  pupils  belonging  to  this  class  cannot 
learn  to  speak  intelligibly  unless  much  more  attention  is  given  to 
their  instruction  than  is  practicable  in  any  public  school. 

The  mediocrity  of  results  attained  is  further  increased  by  the 
mental  inertness  of  deaf-mute  pupils  either  admitted  when  too  old  to 
adapt  themselves  successfully  to  study,  or  retained  too  long  after 
reaching  adolescence. 

The  duty  of  the  State  in  respect  to  the  education  of  the  deaf.  The 
opponents  of  the  proposed  reform  for  teaching  these  defectives  in  the 
public  day-schools  assert  that  the  policy  of  the  State  is  to  exclude  all 
who  cannot  be  regarded  as  having  average  mental  and  physical  quali- 
fications; but  no  one  has  ventured  to  define  this  standard.  Indeed, 
it  would  be  difficult   to  do  so;  and  were   all   of  the   average  pupils 


THK    EDUCATION   OF    DEAF  SCHOOL    CHILDREN.  419 

selected,  what  should  be  done  with  the  remaining  pupils?  This 
question  has  thus  far  been  only  tentatively  met  by  the  attempt  to 
separate  all  pupils  into  good  hearing  and  totally  deaf  classes. 

By  many  it  is  held  that  our  public-school  system  has  for  its  princi- 
pal object  the  prevention  of  illiteracy  among  the  poor,  and,  if  this 
view  be  correct,  it  can  scarcely  be  regarded  as  consistent  on  the  part 
of  the  advocates  of  educating  the  average  child  only  to  oppose  a 
scheme  for  the  promotion  of  the  interests  of  a  needy  but  uninfluential 
class,  while  fostering  expensive  institutions  for  the  free  education  of 
the  better-to-do,  and  going  so  far  even  to  expend  large  sums  of 
money  in  giving  special  instruction  in  German,  French,  music,  etc. 

This  was  certainly  never  contemplated  by  those  who  founded  the 
common-school  system.  Nor  is  it  humane  to  leave  the  care  of  this 
defective  class  to  the  uncertainties  of  philanthropic  aid.  The  State 
already  has  abundant  facilities  for  the  care  of  all  the  deaf-mutes  who 
cannot  be  educated  in  connection  with  the  day  system  of  public 
schools,  and  inasmuch  as  these  institutions  will  soon  be  overcrowded 
by  the  natural  increase  of  this  class,  it  would  seem  that  facilities 
should  be  provided  for  them  in  the  day-schools  without  delay.  There 
are  already  17,000  deaf  and  dumb  persons  of  the  school  age  in  the 
United  States,  according  to  the  census  1880,  only  5,000  of  whom 
were  in  institutions. 

The  expense  of  educating  the  deaf  in  day-schools  as  compared  loith 
their  education  in  institutions.  The  question  of  reform  in  the  educa- 
tion of  the  defective  in  hearing  is  to  a  certain  extent  a  question  of 
expense;  that  they  must  receive  educational  facilities  will  not  be 
denied. 

Let  us  consider  the  result  in  this  regard  of  transferring  to  the  day- 
schools  what  may  be  regarded  as  their  legitimate  share  of  work.  The 
outlay  by  the  State  would  probably  be  lessened,  so  far  as  the  deaf- 
mutes  are  concerned,  and,  on  the  other  hand,  it  would  be  slightly  in- 
creased were  proper  methods  introduced  for  the  instruction  of  the 
very  deaf  and  partially  deaf. 

At  the  present  time  it  costs  the  State  to  support  and  instruct  deaf- 
mutes  in  its  seven  asylums  $250  per  capita  annually.  It  will  thus 
be  seen  that  were  classes  of  ten  formed  in  the  public  schools,  which 
is  probably  a  smaller  number  than  in  asylum  classes,  and  a  teacher 
secured  at  the  rate  of  $800  per  annum,  there  would  be  a  saving  of 
$170  per  pupil.  Where  smaller  classes  of  children  were  formed,  as 
might  be  done  in  the  country,  the  saving  would  be  less.  The  writer 
has  no  exact  figures  upon  which  an  estimate  of  the  number  of  par- 
tially deaf   can   be  based,  but  from  the  large  number  met  with  in 


420  THE    EDUCATION    OF    DEAF    SCHOOL    CHILDKEN. 

practice,  believes  this  to  be  considerable.  These,  however,  could  be 
taught  in  classes  of  twenty,  and  the  increased  expense  would  not  be 
great;  such  pupils  are  at  present  taught,  if  they  attend  school,  in 
classes  with  hearing  children,  and  the  increased  expense  in  reducing 
the  size  of  classes  to  accommodate  them  may  be  easily  computed. 

There  need  be  no  expense  for  new  buildings,  the  structures  at 
present  in  use  for  school  purposes  being  sufficient,  since  it  is  thought 
best  not  to  separate  one  class  from  another  entirely  any  more  than 
the  different  grades  are  now  taught  apart.  Some  instruction  would 
be  common  to  all. 

IMPEEFECTIONS  IN   SPEECH. 

These  are  no  less  vexatious  than  the  disability  arising  from  deaf- 
ness, and,  whilst  often  existing  independently  of  aural  disease,  such 
defects  usually  co-exist.  Their  differentiation  is  important  in  the 
management  of  backward  children,  for  the  subject  may  otherwise  be 
relegated  to  the  class  of  feeble-minded  youth. 

The  correct  enunciation  of  words  depends  very  much  on  a  healthy 
condition  of  the  upper  vocal  organs — the  mouth,  nose,  and  pharynx — 
and  on  the  unobstructed  passage  of  air  through  them  during  vocaliza- 
tion. Repeated  attacks  of  head  colds,  resulting  in  nasal  catarrh,  en- 
largement of  the  tonsils,  congenital  defects  of  the  palate,  etc.,  to- 
gether with  irregularities  of  the  teeth,  are  the  principal  etiological 
factors  in  the  development  of  impediments  that  interfere  with  the 
physiological  functions  of  these  parts.  A  nasal  tone  of  voice  is  an 
almost  invariable  characteristic  of  these  impediments,  but  very  often 
the  obstructions  in  the  throat  or  nose  are  so  great  as  to  give  a 
''  choked  "  expression  to  the  voice.  Enunciation  then  is  difficult; 
for  example,  letters  which  require  for  their  pronunciation  the  use  of 
some  of  these  parts,  as  "  m  "  and  "  n,"  cannot  be  correctly  enunciated. 
When  defects  in  speech  arise  from  disease  in  both  the  ear  and  throat, 
the  pupil  is  placed  at  a  very  great  disadvantage  indeed  as  regards  the 
learning  of  correct  enunciation,  he  fails  to  hear  certain  words  and  on 
the  other  hand  there  are  certain  others  which  he  is  unable  to  enunciate. 
Thus,  the  hissing  sound  of  the  voice  may  not  be  heard  at  all;  the 
pupil  is  therefore  liable  to  leave  it  out  of  his  speech  entirely;  for  ex- 
ample, he  will  pronounce  sir  as  '*thir"and  sausage  as  ''thausig,^* 
and  so  on.  Should  the  deafness  be  very  great,  the  person  will  omit 
such  sounds  entirely,  not  that  he  is  physically  unable  to  make  them, 
but  he  does  not  know  how  they  sound.  Sounds  well  heard  become 
familiar  and  are  soon  learned,  but  slow  hearing  persons  soon  become 
fatigued   with  efforts  at  listening  and  naturally  seem  inattentive. 


THE    EDUCATION    OF    DEAF    SCHOOL    CHILDREN.  421 

Stenographers  who  are  becoming  more  deaf,  begin  to  get  confused; 
"  and  "  sounds  like  "  an  "  etc.  Now,  should  the  pupil  possess  obstruc- 
tions in  the  nose  and  throat  as  well  as  defective  hearing,  instruction 
under  existing  methods  will  be  difficult — in  some  instances  well-nigh 
impossible. 

The  voice,  it  should  be  stated  in  this  connection,  becomes  very 
much  modified  after  the  individual  ceases  to  hear  well;  it  loses  its 
flexibility  and  can  no  longer  be  modulated. 

Children  suffering  from  autophony  or  false  hearing  are  often 
greatly  bothered,  since  this  phenomenon  may  confound  even  the  most 
intelligent  person,  so  difficult  is  it  to  understand  why  the  seemingly 
strange  alteration  in  voice  should  occur,  and  though  not  attended 
with  imperfect  speech,  may  be  considered  here. 

Autophony  '  occurs  during  the  progress  of  most  aural  diseases.  It 
consists  in  hearing  one's  own  voice  in  the  head;  it  sometimes  amounts 
to  simply  this,  bnt  there  is  often  heard  a  reverberation  of  the  voice, 
or  an  "echo,"  as  it  is  often  styled,  and  it  is  then  described  by  the 
sufferer  as  double  hearing.  When  the  patient  thus  hears  his  own 
voice,  he  fancies  that  others  cannot  hear  him  talk,  for  the  voice  seems 
to  go  up  into  the  affected  ear  instead  of  going  out  of  the  mouth.  The 
effort  of  talking  becomes  very  tiresome  to  him,  for  no  exertion,  how- 
ever great,  is  of  any  avail;  the  louder  he  tries  to  speak  the  more  dis- 
agreeable his  voice  sounds  in  his  own  ear. 

The  autophonous  voice  sounds  very  strange  to  the  patient;  it  is  un- 
like his  own  voice;  it  seems  as  though  another  person,  at  a  distance, 
were  speaking.  When  the  voice  is  thus  heard  false  by  the  pupil,  he 
is  unable  to  regulate  or  control  it,  for,  in  many  instances  at  least,  at 
one  moment  it  may  sound  quite  naturally,  as  though  in  fact  it  came 
out  of  his  mouth  and  went  around  to  the  ear  as  usual,  while  the  next 
moment  it  seems  to  fail  of  utterancea  Itogether  and  reaches  the  ear 
from  within  the  head. 

In  false  hearing,  the  voice  usually  appears  to  be  hoarse,  the  patient 
often  calling  one's  attention  to  this  with  the  remark  that  he  must  have 
caught  cold.  Sometimes  the  voice,  however,  seems  to  the  sufferer  to 
be  very  high  in  pitch.  When  hearing  it  higher  than  it  should  be,  the 
patient  makes  an  unsuccessful  effort  to  correct  the  fault  by  lowering 
his  voice,  often  to  a  whisper;  when  it  seems  "  hoarse  "  and  low,  the 
attempt  to  correct  the  apparent  defect  results  in  an  unpleasantly  loud 

'  The  number  of  persons  who  (without  aural  disease)  possess  these  peculiari- 
ties is  comparatively  few,  as  far  as  is  known,  but  as  attention  is  directed  to  these 
conditions,  it  is  probable  that  the  number  will  be  found  to  be  considerable. 


422  EXTENT   OF    DEAFNESS   IX    SCHOOLS. 

voice.  For  further  remarks  on  this  subject  the  reader  may  consult 
Chapter  XVI. 

With  the  fancy  that  it  has  been  deprived  of  the  ability  to  speak,  the 
voice  failing  of  utterance,  comes  the  conviction  of  "dumbness,"  and 
with  the  feeling  comes  the  peculiar  ''  dumb"'  expression.  But  this  is 
by  no  means  always  the  entire  experience  of  the  sufferer,  for  the  voice, 
which  has  been  said  to  seem  to  fail  of  utterance,  seems  to  ascend  into  the 
head,  where  its  unusual  reverberations  give  rise  to  the  belief  that  the 
head  is  "  hollow  "or  "empty."  These  are  alarming  symptoms,  and,  in- 
asmuch as  they  recur  with  every  attempt  at  speech,  tbe  child  fears  to 
make  an  effort  which  is  attended  by  such  disagreeable  symptoms. 

Noises  in  the  head  are  seldom  absent  when  autophony  exists.  The 
character  of  the  noise  depends  very  much  on  the  imagination  of  the 
patient,  and  may,  therefore,  be  said  to  be  variable;  but  it  is  also  in- 
fluenced greatly  by  changes  in  the  transmitting  mechanism.  In  the 
worst  cases,  the  patient  hears  the  rushing  of  a  railway  train  in  the  head 
or  the  raging  of  a  storm;  these  noises  are  attended  by  sounds  of  ring- 
ing bells,  pattering  hail  or  rain,  etc.  When  the  patient  has  an  inter- 
val of  relief,  the  noises  are  more  bearable;  they  may  then  be  likened 
to  the  gentle  sighing  of  the  wind  among  the  trees,  the  play  of  the 
surf  on  the  sandy  beach,  the  singing  of  the  tea  kettle,  the  buzzing  of 
insects,  etc.  Patients  usually  describe  these  noises  as  resembling 
some  familiarly  remembered  sound;  thus  the  distant  roar  of  a  water- 
fall occurs  to  one,  or  the  pattering  rain  to  another,  whose  memory 
goes  back  to  the  days  when  he  slept  just  beneath  the  roof.  But  very 
often  the  imagination  fails  to  aid  in  the  description,  and  with  chil- 
dren the  difficulties  in  the  way  of  finding  out  their  feelings  are  almost 
insurmountable. 

Whilst  these  symptoms  are  usually  of  brief  duration  in  a  large 
number  of  cases,  some  of  them  become  permanent. 

EEMARKS  ON    THE  EXTENT  OF  DEAFNESS  IN  THE 

SCHOOLS. 

In  considering  the  relations  of  all  classes  of  deaf  pupils  with  both 
the  public  day  schools  and  deaf-mute  schools  from  the  physician's 
point  of  view,  it  is  believed  that  the  extent  and  importance  of  the 
subject  may  be  more  fully  realized  than  in  any  other  way,  since  where 
professional  advice  is  required  opportunity  is  allowed  for  thorough 
examination  of  the  hearing  organs,  both  as  regards  their  physical 
condition  and  acoustic  functions.  A  very  considerable  experience, 
including  observations  on  a  large  number   of   specially   interesting 


EXTENT    OF    DEAFNESS    IN    SCHOOLS.  423 

cases  among  school  children  of  the  poorer  class,  seen  in  hospital  prac- 
tice, led  the  writer  to  believe  that  great  injustice  was  being  done  in 
permitting  children  to  struggle  for  an  education  under  the  disad- 
vantages arising  from  deafness  without  the  aid  of  methods  which  ex- 
perience had  shown  to  be  advantageous  in  such  cases;  he  therefore 
concluded  to  make  some  efforts  in  their  behalf,  and  in  1877  the  mat- 
ter was  brought  to  the  notice  of  the  Board  of  Education  of  New 
York. 

The  Board  referred  the  matter  to  the  Committee  on  Teachers,  and 
in  explaining  the  matter  to  them  it  was  shown  that  some  children 
continued  on  at  school,  for  years  even,  while  scarcely  any  hearing  re- 
mained, while  there  were  many  others  who  heard  very  badly;  that  in 
disregarding  this  matter  deaf  children  were  placed  at  a  serious  disad- 
vantage, and  that  the  time  wasted  in  futile  attempts  to  instruct  them 
was  a  hindrance  to  others.  Instances  of  special  injustice  were  cited 
where  children,  defective  in  hearing,  had  made  great  efforts  both  at 
school  and  at  home  to  prepare  themselves  for  promotion,  only  to  be 
put  back  on  examination,  because  the  principal  was  not  aware  of  the 
child's  imperfection,  and  therefore  had  not  given  his  questions  dis- 
tinctly enough  to  be  heard.  Other  deaf  children,  from  neglect  to 
classify  them,  were  seated  too  far  away  from  the  teacher's  desk  to 
hear  his  voice,  and  in  consequence  of  inability  to  reply  correctly  were 
frequently  punished  for  inattention  and  dulness.  The  rudeness  often 
practised  toward  these  unfortunate  pupils  by  unthinking  or  unsym- 
pathetic teachers  was  discouraging,  and  some  pupils  in  consequence 
had  left  school  altogether. 

It  was  not  recommended  at  this  time  that  the  partially  deaf  should 
be  entirely  separated  from  the  hearing  pupils,  yet  it  was  advised  that 
pupils  should  be  always  examined  with  regard  to  their  hearing,  and 
that  those  found  to  be  defective  should  be  given  every  possible  ad- 
vantage, both  in  respect  to  seating  and  to  distinctness  of  voice  in 
teaching,  the  very  deaf  should  have  some  instruction  apart  from 
others,  since  they  often  could  not  understand  words  shouted  into 
their  ears.  The  writer  did  not  expect  that  the  long-established  order 
of  things  could  be  rapidly  changed,  but  it  is  believed  that  teachers 
have  become  more  interested  in  the  subject  than  before,  and  that  in- 
stances of  "inattention"  and  "stupidity"  are  less  puzzling  since 
their  true  character  is  recognized.  Complaints  are  now  less  fre- 
quently made  by  pupils  who  come  for  treatment  of  neglect  in  this  re- 
gard, and,  indeed,  teachers  very  often  recommend  that  deaf  children 
be  brought  to  our  clinics  for  relief.  No  special  .action,  however,  was 
taken  at  this  time. 


424  EXTENT   OF    DEAFNESS    IN    SCHOOLS. 

In  the  mean  time  the  subject  of  deafness  among  school  children  at 
tracted  the  attention  of  the  Educational  Department  of  the  United 
States  Government,  and  the  matter  being  considered  important 
enough  to  justify  a  special  investigation  of  its  causes,  the  writer 
was  requested  to  prepare  a  paper  on  the  subject,  which  was  printed 
by  the  Bureau  of  Education  for  distribution  in  1881. 

In  order  to  obtain  accurate  data  upon  which  a  report  to  the  Com- 
missioner of  Education  might  be  made,  the  writer  concluded  to 
institute  some  examinations  of  the  pupils  in  the  public  and  parochial 
schools  of  New  York  with  the  view  of  ascertaining  the  percentage  of 
deafness  and  the  state  of  aural  hygiene  among  them. 

Being  aware  of  the  fact  that  deafness  existed  in  numerous  cases 
where  an  examination  only  would  convince  the  patient  of  the  fact, 
the  writer,  in  conducting  the  school  examinations,  first  interrogated 
both  the  teachers  and  the  pupils  as  to  their  own  knowledge  of  any 
deafness;  their  replies  and  the  subsequent  lack  of  verification  are  sig- 
nificant. It  should  be  stated  that  these  examinations  were  made 
under  circumstances  unfavorable  to  the  attainment  of  such  results  as 
would  be  required  for  an  exact  classification  of  pupils,  for  at  the  visi- 
tations the  children  were  sometimes  found  at  their  recitations  or  when 
they  were  on  the  eve  of  dismissal.  But  the  results,  though  obtained 
under  difficulties,  are  thought  not  to  be  without  value.  For  his  gen- 
eral conclusions  on  this  subject,  however,  the  writer  has  relied  on  the 
thorough  examinations  made  of  individual  cases  which  have  been 
brought  to  him  for  treatment ;  in  these  the  tests  of  the  hearing  power 
were  made  deliberately,  and  the  statements  of  parents  regarding  the 
cases  were  also  obtained. 

Five  hundred  and  seventy  pupils  were  examined  ;  they  were  dis- 
tributed as  follows  : 

In  the  colored  public  schools 261 

In  the  Roman  Catholic  parochial  schools 226 

In  the  white  public  schools 83 


570 


An  analytical  review  of  the  details  of  these  examin  .tions  as  ex- 
hibited in  the  tables  '  shows,  that  of  the  five  hundred  and  seventy 
pupils  examined,  the  teachers  were  previously  aware  of  the  existence 
of  one  case  of  deafness  only,  while  the  pupils  themselves  were  but 

'  The  details  of  theae  examinations  may  be  consulted  in  the  tables  appended 
at  the  end  of  Circular  No.. 5  (Bureau  of  Education),  Washington,  1881. 


EXTENT   OF    DEAFNESS    IN    SCHOOLS.  425 

little  better  informed,  only  nineteen  of  the  number  being  aware  of 
their  aural  defects.  In  his  own  examinations,  which  were  by  no 
means  searching  and  in  which  the  teachers  usually  gave  the  test  ques- 
tions with  the  intent  of  compelling  the  children  to  hear  them,  the 
writer  detected  seventy  six  cases,  or  about  13  per  cent,  of  greatly 
diminished  hearing  in  one  or  both  ears. 

Four  hundred  and  eighty-seven  of  the  entire  number  of  pupils  were 
asked  if  they  had  ever  experienced  earaches;  one  hundred  and  seventy- 
three  of  them,  or  out  36  per  cent,  recollected  having  had  this  symp- 
tom. Among  the  other  children  but  few  had  any  recollection  of  ever 
having  had  pains  in  the  ears,  probably  because  past  pains  are  soon 
forgotten.  In  all  of  these  instances  where  earache  had  been  experi- 
enced it  may  be  inferred  that  the  aural  affection  that  gave  rise  to 
them  had  also  more  or  less  permanently  damaged  the  sense  of  hear- 
ing ;  but  such  defects  would  not  be  apparent  unless  more  delicate  tests 
were  made. 

Believing  that  the  time  had  arrived  when  more  advantageous  action 
might  be  taken  in  New  York,  the  Board  of  Education  was  again  in- 
duced to  take  the  matter  into  consideration  in  1884,  a  communication 
on  the  subject  from  the  writer  having  been  referred  to  the  Committee 
on  "  Course  of  Studies."  The  Committee  met  on  November  12th,  and 
on  invitation  the  writer  presented  some  typical  cases  of  aural  disa- 
bilities in  children,  and  gave  the  results  of  his  experience  concerning 
deafness  in  the  schools. 

At  the  meeting  of  the  Committee,  December  17th,  1884,  the  fol- 
lowing resolutions  were  adopted:  1.  ''  That  it  is  inexpedient  to  es- 
tablish special  schools  or  special  classes  in  existing  schools  for  the  in- 
struction of  the  partially  deaf."  2.  "  That  the  City  Superintendent 
be  instructed  to  require  class  teachers  to  investigate  and  observe 
respecting  physically  imperfect  capacities  of  sight  and  hearing  among 
the  pupils,  and  to  assign  seats  and  positions  in  class  rooms  to  pupils 
so  as  to  relieve,  as  far  as  may  be,  disability  arising  from  such  causes; 
and,  further,  that  in  examination  of  classes  by  the  Assistant  Superin- 
tendents, observation  and  report  be  made  to  the  City  Superintendent 
M'ith  reference  to  compliance  with  this  requirement." 

The  following  is  an  estimate  of  the  extent  of  aural  disabilities  in 
the  United  States.  Careful  estimates  have  been  made,  indicating 
than  no  greater  number  than  five  per  cent  of  the  entire  population 
have  normal  hearing,  but  this  of  course  does  not  show  the  number  of 
persons  defective  enough  to  exclude  them  from  the  benefits  of  the 
ordinary  common-school  curriculum.  The  tenth  census  computes 
that  there  are  about  thirty-four  thousand  deaf-mutes  in  the  United 


^6  DEAFNESS  AMONG  TEACHERS. 

States,  or  one  out  of  every  one  thousand  five  hundred.  One-half  of 
these  are  illiterate. 

Estimate  of  the  extent  of  aural  disahilities  in  the  schools  of  New 
York  City.  In  1884,  nearly  four  thousand  deaf-mutes  resided  in  the 
State  of  New  York,  and  over  one  thousand  in  this  city.  Of  the  lat- 
ter, five  hundred  and  seventy-five  were  in  asylums.  The  number  of 
totally  deaf  persons  of  the  school  age  in  this  city,  but  outside  of  asy- 
lums, was  stated  to  be  one  hundred  and  sixty-three;  but  the  estimate 
is  much  too  low,  since  the  enumeration  of  the  census-takers  was  very 
unreliable  in  respect  to  this  class.  Parents  are  slow  to  acknowledge 
their  deaf-mute  progen}',  and  often  the  census-takers  make  no  efforts 
to  get  at  the  facts.  The  writer  has  met  with  a  considerable  number 
of  these  children  who  were  not  enumerated,  and  he  doubts  not  that 
there  are  no  less  than  five  hundred  of  them  in  this  city,  of  the  school 
age,  unprovided  with  educational  facilities. 

Before  the  census  of  1880  was  taken,  the  question  of  ascertaining 
the  number  of  very  deaf  people  was  considered  by  the  special  agent, 
Mr.  Wines,  but  the  scheme  was  abandoned,  as  it  was  thought  that 
any  returns  of  this  kind  would  be  wholly  unreliable  unless  obtained 
by  the  aid  of  expert  examiners.  It  is,  therefore,  impossible  to  give 
a  very  close  estimate  of  their  number;  but  if  one  may  form  an  opinion 
from  experiences  in  practice,  the  numter  having  more  or  less  dis- 
qualifying aural  defects  may  be  put  down  at  no  less  than  ten  per  cent 
of  the  entire  school  population  of  New  York  City.  Thus  out  of 
about  one  hundred  and  forty  thousand  pupils  in  attendance  at  the 
public  schools  in  1884,  some  fourteen  thousand  of  them  would  be  the 
better  for  classification  in  respect  to  seating  and  instruction  at  close 
range,  or  by  means  of  some  aid  to  hearing.  These  figures  show  that 
we  have  to  deal  with  a  vast  number  of  defectives,  in  respect  to  hear- 
ing, and  although  this  avenue  to  illiteracy,  and  consequently  to  pau- 
perism, was  not  of  much  significance  when  the  country  was  new,  it 
surely  demands  our  attention  now,  when  vagrancy  and  kindred  evils 
are  attracting  so  much  attention  from  the  vastness  of  their  propor- 
tions. 

DEAFNESS   AMONG  TEACHERS. 

It  is  not  unfair  to  state  that  teachers  do  not  enjoy  greater  immu- 
nity from  impairments  of  the  sense  of  hearing  than  others  in  the 
same  social  position;  and,  although  a  certain  degree  of  deafness 
should  not  exclude  a  person  otherwise  competent  from  the  pedagogi- 
cal profession,  yet  it  must  be  confessed  that  good  hearing  is  very 


DEAFNESS   AMONG    TEACHERS.  427 

essential  to  one  who  has  so  many  experiences  to  try  his  temper,  and 
who  should  be  able  to  avoid  doing  an  injustice  to  any  pupil  from  a 
failure  to  hear  everything  that  is  said  in  his  presence.  Should  an  in- 
structor himself  be  defective  in  his  hearing  sense,  and  yet  be  unaware 
of  the  fact,  it  would  be  easy  for  him  to  unjustly  censure  children  for 
incompetency  in  the  course  of  instruction  or  in  examinations  for  pro- 
motion simply  because  their  responses  were  not  heard.  The  writer 
has  known  instances  where  teachers  when  suffering  from  temporary 
deafness  were  almost  sure  to  hear  certain  words  incorrectly,  and  were 
therefore  obliged  to  ask  pupils  to  repeat  their  replies  over  and  over 
again  before  they  could  assure  themselves  of  their  correctness.  Such 
experiences  are  a  warning  to  those  having  irremediable  defects. 

Persons  desirous  of  acquiring  a  pedagogical  education  at  the  public 
expense  should  be  subjected  to  an  aural  examination  before  they  are 
accepted;  and  in  the  appointment  of  teachers  in  the  public  schools 
the  ability  to  hear  well  should  be  a  requisite.  If  the  examinations 
were  always  oral,  the  applicants  being  required  to  hear  the  questions, 
they  would  be  more  satisfactory  than  if  otherwise  conducted.  The 
author  has  in  mind  an  illustrative  case  which  is  of  interest  in  this 
connection:  A  young  woman  nineteen  years  old  had  been,  it  was  sup- 
posed, thoroughly  prepared  for  teaching,  but  she  gradually  became 
so  deaf  that  when,  after  graduation,  she  appeared  before  a  Brooklyn 
board  of  examiners  for  appointment  as  a  teacher  in  the  public  schools, 
she  utterly  failed.  The  questions  were  given  out  orally,  and  she  was 
unable  to  answer  them  because  of  her  inability  to  hear  them  correctly. 
The  board  of  examiners,  however,  was  not  aware  of  her  aural  defect. 
Had  the  same  attention  been  given  in  the  case  of  this  person  to  the 
condition  of  the  ears  that  was  devoted  to  her  mental  improvement, 
her  success  would  probably  have  been  assured. 


CHAPTER    XIX. 

The  Effect  of  High  Atmospheric  Pressure  on  the  Ear  in  Tunnels,  Oaissons, 

etc.     The  Effect  of  Submarine  Diving  on  the  Ear.     The  Effect  of 

Sudden  Rarefaction  of  Air  externally  to  the  Drum. 

THE    EFFECT    OF    HIGH    ATMOSPHERIC    PRESSUEE 
ON  THE  EAR  IN  TUNNELS,  CAISSONS,  ETC. 

The  effect  of  subjecting  the  ears  to  high  atmospheric  pressure  dif- 
fers, when  gradually  accomplished,  from  the  sudden  concussion  of  ex- 
plosives, as  by  the  blast  of  great  guns  or  boxing  the  ear.  The  injuries 
under  discussion  mostly  arise  from  going  into  submarine  caissons, 
though  submarine  divers,  as  is  mentioned  elsewhere,  often  experience 
unpleasant  aural  symptoms  from  this  cause.  The  writer  has  had  fre- 
quent opportunity  for  studying  the  effect  of  undue  atmospheric 
pressure  on  the  ear  since  the  construction  of  the  Hudson  River  Tunnel 
was  commenced,  some  seven  or  eight  years  ago,  a  number  of  the 
employes  having  come  to  his  aural  clinic  at  the  New  York  Eye 
and  Ear  Infirmary,  on  account  of  the  injury  done  to  their  ears.  It  is 
well  known  that  the  atmosphere  in  which  we  live  has  a  pretty  uniform 
pressure  upon  the  body  of  about  fifteen  pounds  to  the  square  inch. 
Now,  any  decided  variation  from  such  tension  is  liable  to  give  rise  to 
discomfort,  and  this  is  just  what  takes  place  in  submarine  caissons, 
where  the  pressure  is  sometimes  four  or  five  times  greater.  Persons 
about  to  be  subjected  to  the  greatly  increased  aerial  pressure  of  a 
caisson  are  prepared  for  it  gradually  by  means  of  a  so-called  lock,  or 
air-tight  chamber,  which  they  enter  and  occupy  until  enough  com- 
pressed air  is  gradually  forced  in  to  enable  them  to  pass  on  into  the 
working-chamber,  where  pressure  is  maintained  as  in  the  lock, 
namely,  twenty  to  forty  pounds,  or  more,  to  the  square  inch.  The 
practical  information  obtained  by  the  writer  on  this  subject  from  one 
who  had  worked  in  the  Hudson  River  Tunnel  for  two  years  and  eight 
months  is  of  interest.  The  informant,  an  Irishman,  had  worked 
about  one-half  of  the  period  above  mentioned  under  a  pressure  of 
about  twenty-six  pounds  to  the  square  inch,  but  often  under  much 


EFFECT   OF    HIGH    ATMOSPHERIC   PRESSURE.  429 

greater  pressure.  At  the  Jersey  City  terminus,  where  he  was  em- 
ployed, more  pressure  was  required  in  tunnelling  than  at  the  New 
York  end.  The  atmosphere  was  always  humid,  and  the  workmen 
were  obliged  to  stand,  while  freely  perspiring,  in  more  or  less  water, 
which  everywhere  was  oozing  in.  He  stated  that  his  ears  were  never 
affected,  nor  were  his  son's,  though  the  latter  commenced  to  work 
in  the  caisson  four  years  ago,  at  the  age  of  fifteen  years,  and  remains 
there  up  to  the  present  time.  He  and  his  son  are  both  of  them  healthy 
and  sober.  They  have  been  well  while  working  in  the  tunnel, 
neither  of  them  ever  having  had  the  "  bends.''  He  relates  that  he 
could  whistle  under  a  pressure  of  twenty-four  pounds — a  diflBcult  feat, 
it  would  seem,  since  possible  to  but  few  even  under  a  pressure  of 
twenty-two  pounds. 

It  may  be  premised  here  that  were  healthy  and  sober  men,  free 
from  pre-existing  aural  trouble,  only  employed,  there  would  be  much 
less  suffering  from  ear,  or,  indeed,  other  disease  among  caisson- 
laborers.  But,  unfortunately,  many  improper  subjects  are  permitted 
to  enter  into  this  branch  of  labor,  only  soon  to  be  discharged  with  im- 
paired health,  and  often  irremediable  ear  disease.  The  importance 
of  this  subject,  the  writer  believes,  will  justify  the  introduction  here 
of  several  illustrative  cases  from  among  others  which  came  under  his 
observation : 

One  individual,  aged  thirty,  asserted  that  on  several  occasions,  after 
descending  the  shaft  and  going  into  the  lock,  he  had  attempted  to 
remain  while  the  condensed  air  was  forced  in,  but  each  time  the  dis- 
tress in  his  ears  had  prevented  him,  until  finally  he  forced  himself 
to  go  to  work  in  the  caisson  while  still  enduring  much  distress.  The 
effect  of  the  great  pressure  proved  most  disastrous,  for  he  was  after- 
ward laid  up,  for  a  long  time,  with  purulent  inflammation  of  both 
ears. 

Another  person,  whose  case  was  similar  to  the  foregoing,  stated  that 
the  distress  on  submitting  to  the  increased  pressure  in  the  lock  was  so 
great  that  he  was  obliged  to  scream  out  from  the  pain  in  his  ears, 
demanding  repeatedly  to  be  liberated,  but  the  man  in  charge  jeered 
"him  and  he  was  forced  to  go  to  work.  In  consequence  of  the  injury 
occurring  to  the  ears,  he  had  been  prevented  from  performing  any 
labor  for  a  long  time. 

Case  1. — Lawrence  C ,  aged  25,  a  bricklayer,  came  to  the  New 

York  Eye  and  Ear  Infirmary,  March  4th,  1880.  Patient  began  to 
work  in  the  air  chamber  of  the  Hudson  River  Tunnel  three  days  ago. 
Works  eight  hours  daily.  From  the  start  there  was,  on  first  coming 
out  of  the  compressed  air,  a  sensation  of  "  cracking  air,"  or  rapid 


430  EFFECT   OF    HIGH    ATMOSPHERIC    PRESSURE. 

concussions  like  "  bubbles  of  air  exploding  "  in  the  ears,  but  mostly  in 
the  right  one.  While  at  work  he  is  very  deaf,  and  has  tinnitus  and 
vertigo,  symptoms  which  have  become  worse  daily.  Examination 
showed  the  anteiior  superior  quadrant  of  the  right  drum-head  to  be 
highly  hyperasmic.  The  left  external  auditory  canal  was  found  to 
contain  a  large  plug  of  inspissated  wax,  the  impaction  of  which  froin 
the  atmospheric  pressure  gave  rise  to  the  vertigo  and  tinnitus.  His 
teeth  are  bad,  and  he  is  subject  to  head  catarrh. 

Case  2. — Patrick  C^ ,  31  years  of  age,  came  to  the  New  York 

Eye  and  Ear  Infirmary,  April  28th,  1882,  complaining  of  earache  on 
the  left  side.  Three  weeks  ago  he  had  begun  to  work  in  the  caisson 
of  the  Hudson  River  Tunnel,  and,  on  account  of  the  exposure,  soon 
contracted  a  severe  head  cold,  followed  in  about  four  days  by  acute 
purulent  inflammation  of  the  left  ear.  It  began  with  severe  pain  in 
the  ear,  which  lasted  for  three  days,  when  a  discharge  set  in,  which 
continues.  There  is  intermittent  pain  in  the  right  ear.  The  division 
of  workmen  to  which  he  belonged  labored  for  eight  hours  and  then 
rested  for  sixteen  hours.  He  has  frontal  headache,  and  pain  in  swal- 
lowing. 

Examination  of  ears  :  Left  canal  filled  with  pus.  Tenderness  over 
left  mastoid  process,  extending  down  to  its  apex.  The  right  drum- 
head is  hyperasmic,  and  has  a  dusky  look. 

Hearing  :  Loud  voice  only  in  the  left  ear ;  ordinary  voice  in  the 
right  ear. 

The  patient's  throat  gives  evidence  of  long-standing  inflammation, 
the  mucous  membrane  being  thickened  and  vascular.  The  tonsils  are 
enlarged  and  the  teeth  are  very  defective. 

Case  3. — Richard  F ,  38  years  of  age,  came  to  the  infirmary, 

October  3Uth,  1882.  Never  had  any  aural  disease  before  working  in 
the  caisson  of  the  Hudson  River  Tunnel,  when  his  ears  began  to  be 
"blocked  up''  in  passing  through  the  lock,  and  yesterday  morning, 
when  arising  from  bed,  the  left  ear  was  painful  and  felt  "blocked." 
The  entire  head  soon  ached,  and  pains  extending  down  the  back.  In 
a  short  time  pain  and  pressure  were  experienced  in  the  right  ear.  On 
reporting  at  the  works  their  physician  gave  him  cotton  saturated  with 
some  fluid  to  use  in  his  ears,  but  the  pains  continued  to  get  worse. 
Patient  worked  for  four  hours,  and  then  rested  for  nine  hours,  while 
employed.    • 

Examination  shows  the  loft  drum-head  to  be  very  hyperaBmic,  the 
posterior  superior  quadrant  bulging,  more  highly  congested  in  one 
spot,  which  seems  on  the  point  of  giving  way.  The  right  drum-head 
is  very  hyperaemic  at  upper  border  and  down  the  malleus  plexus.  He 
has  decided  nasal  catarrh,  and  the  mucous  membrane  of  the  throat  is 
very  vascular  and  thickened.  Hears  loud  voice  only  in  either  ear.  Is 
autophonous  in  the  right  ear. 

Case  4. — John  D ,  aged  23,  came  to  New  York  Eye  and  Ear 

Infirmary,  January  29th,  1883.  States  that  after  working  in  Hudson 
River  Tunnel  for  six  months  his  right  ear  began  to  trouble  him  and 


EFFECT    OF    HIGH    ATMOSPHERIC    PRESSURE.  431 

he  had  to  stop  working  ;  it  has  been  discharging  for  three  months. 
The  left  ear  began  to  discharge  also  about  a  month  ago — two  months 
after  leaving  the  tunnel-work. 

The  discharge  in  right  ear  began  with  otalgia;  the  left  ear  has  not 
pained.  The  tinnitus  is  very  distressing,  but  intermits.  On  begin- 
ning work  the  right  ear  got  '^  blocked"  on  going  into  the  "  lock," 
and  felt  ''dumb"  for  a  month  afterward.  In  fact,  both  of  his  ears 
often  got  "  blocked,"  but  by  blowing  his  nose,  or  holding  it  over 
steam,  the  sensation  of  being  stopped  up  in  his  ears  passed  off.  He 
worked  in  water  much  of  the  time,  and  was  much  exposed.  Con- 
fesses to  syphilis  and  intemperance.  Examination  shows  that  a  perfora- 
tion exists  in  anterior  superior  quadrant  of  left  ear.  Canal  of  right 
ear  narrowed  to  a  slit-like  passage,  so  that  drum-head  cannot  be 
seen;  both  canals  contain  purulent  matter.  He  has  very  decided  nasal 
catarrh. 

Case  5. — Michael  McC ,  aged  twenty-six,  came  to  the  infirmary, 

April  12th,  1887.  Was  never  deaf  before  being  employed  on  the  Harlem 
Eiver  bridge.  He  entered  the  caisson  under  Harlem  River  a  month 
ago,  and  remained  at  work  one  ''shift"  of  eight  hours  only.  The 
pressure  was  considerable,  but  the  exact  amount  was  not  known.  He 
states  that  soon  after  going  into  the  lock,  with  two  other  laborers,  air 
began  to  be  forced  in.  He  began  to  feel  very  uncomfortable;  thought 
his  head  would  "  blow  off ;"  his  eyes  seemed  to  "pop  out,"  and  his 
ears  "cracked."  The  "boss"  told  him  to  hold  the  nose,  close  his 
mouth  and  not  to  breathe.  He  tried  to  follow  these  directions  for  a 
couple  of  minutes,  and  on  taking  his  hand  from  the  nose  it  bled. 
He  then  shouted  to  be  let  out,  but  the  men  in  the  lock  said  he  would 
soon  get  used  to  it,  that  the  first  time  was  the  most  severe.  But  the 
distress  continued,  and  while  thus  holding  the  nose  and  shouting  out 
for  relief  some  thirteen  minutes,  he  was  let  into  the  caisson  under  the 
river,  where  he  worked  for  eight  hours,  though  very  dizzy  and  weak 
in  the  back.  On  coming  out  of  the  caisson  he  was  very  deaf — felt  as 
though  he  could  not  speak.  He  speaks  very  loud,  for  fear  others  will 
not  hear.  These  symptoms  remain,  and  he  has  "cracking'  in  ears 
on  swallowing.  Has  had  pains  for  two  days  about  the  outer  canthus 
of  right  eye. 

Hearing:  Loud  voice  only  in  right  ear  at  twenty  feet;  left  ear  low 
voice,  if  plain. 

The  drum-heads  are  dry,  lustreless-looking,  and  greatly  blackened 
with  dust,  the  atmosphere  of  the  caisson  being  full  of  gunpowder 
smoke.  The  short  process,  and  the  handles  of  the  malleus  on 
iDoth  sides  look  bleached,  and  stand  out  in  strong  relief  from  the 
blackened  membranes.  The  dermic  layer  of  the  right  drum-head  is 
blistered  off  in  places,  especially  behind  the  short  process.  There  are 
new  blebs  on  anterior  segment,  and  posteriorly  on  the  flaccid  mem- 
brane. 

Patient  had  long  been  a  hard  drinker,  and  for  a  week  before  work- 
ing in  the  caisson  had  had  a  severe  head  cold.  Ever  since  the  injuiy 
he  has  been  "  spreeing,"  and  the  head  catarrh  has  not  abated.     The 


432  EFFECT    OF    HIGH    ATMOSPHERIC    PRESSURE. 

teeth  are  pretty  bad,  and  he  has  been  subject  to  nasal  catarrh  for  a, 
long  time. 

The  cause  of  aural  trouble  among  caissonists  is  evident  from  a 
study  of  the  foregoing  cases,  when  the  disturbances  produced  by 
high  air-pressure  on  the  organ  of  hearing  are  considered.  Thus, 
the  usual  intra-tympanal  air-supply  having  been  cut  off  by  closure 
of  the  guttural  mouth  of  the  Eustachian  tube  (as  from  head  colds 
due  to  exposure,  or  naso-pharangeal  catarrh,  or,  perhaps,  from  con- 
densation of  pharyngeal  air),  it  is  found  that  the  effect  of  great  aerial 
pressure  upon  the  outer  surface  of  the  drum-head  is  to  force  it  inward. 
This  causes  undue  tension  of  the  transmitting  mechanism,  as  well  as 
congestion  or  inflammation  of  the  drum.  As  the  air  of  the  drum 
decreases  by  absorption,  or  escapes  into  the  Eustachian  tube  in  con- 
sequence of  unusual  outward  pressure,  retraction  of  the  drum-head, 
of  course,  gives  raise  to  pain,  deafness,  tinnitus,  vertigo,  and  other 
distressing  symptoms  in  the  ears  and  head.  Where  there  is  a  collec- 
tion of  wax  in  the  auditory  canal  it  is  extremely  liable  to  become 
softened  in  such  a  humid  atmosphere,  especially  if  perspiration  be 
free,  and  when  loosened  in  this  manner  the  plug  becomes,  as  in  one 
of  the  above  cases,  impacted  against  the  drum-head,  causing  great 
discomfort.  Through  carelessness  in  charging  the  lock  with  con- 
densed air,  and  the  neglect  of  its  inmates  during  the  process  to  main- 
tain tympanal  air-renewal  (by  making  frequent  efforts  to  inflate  the 
drum  when  the  nose  is  held  closed,  by  blowing  air  from  the  lungs  up 
into  the  head  while  the  mouth  is  closed),  much  aural  trouble  is  likely 
to  be  experienced  by  any  one  exposed,  though  having  sound  ears,  for 
during  the  loss  of  equilibrium  the  strain  upon  the  parts  gives  rise  to 
more  or  less  hyperaemia.  Rupture  of  the  drum-head  is  said  to  be 
possible  under  these  circumstances,  but  such  a  result  must  be  ex- 
ceptional unless  condensation  is  very  sudden. 

On  going  out  from  the  lock  into  air  of  ordinary  tension  compressed 
air  may  remain  confined  in  the  drum,  and  on  its  expansion  the 
drumhead  is  liable  to  be  forced  outwardly.  Such  being  the  fact,  it 
behooves  persons,  in  passing  out  of  a  caisson-lock  where  high  pressure 
is  maintained,  to  exercise  care  as  on  going  in.  But  where  great 
tension — ^from  forty  to  sixty  pounds — is  required,  as  in  tunnel- 
work,  it  seems  probable  that  unpleasant  effects  on  the  ear  can  scarcely 
be  avoided,  and  the  greater  number  who  have  pre-existing  aural 
trouble  will  be  liable  soon  to  become  more  or  less  incapacitated. 
Men  seeking  employment  in  this  work,  as  in  any,  would  often  conceal 
their  aural  or  other  physical  defects,  as  well  as  fail  to  report  any  dis- 


EFFECT   OF    SCBMAIIINE    Dn'ING   ON    THE    EAR.  433 

ease  incident  to  the  exposure  of  their  unhealthful  occupation,  and 
unless  a  competent  medical  examination  be  made  of  every  man  before 
being  employed,  and  at  frequent  intervals  afterward,  great  injustice 
may  be  done  to  the  laborer  himself.  Deaf  persons  are,  moreover, 
incompetent  in  any  capacity  where  their  own  and.  others^  safety  may 
depend  on  hearing  what  is  said  to  them  in  emergencies.  Defective 
persons,  such  as  have  been  reported  above,  are  manifestly  unfit  to  be 
employed  in  work  under  highly  compressed  air, 

THE   EFFECT   OF    SUBMARINE    DIVING    ON    THE   EAR. 

In  tropical  and  semi-tropical  countries  a  large  number  of  persons 
engage  in  submarine  diving  for  a  livelihood;  pearls  and  sponges,  for 
example,  being  obtained  in  this  way.  Travellers  in  those  countries 
are  familiar  with  the  practice  among  the  natives  of  frequently  diving 
in  sport,  and  it  would  be  of  interest  to  know  to  what  extent  their  ears 
are  affected. 

The  writer  requested  his  friend.  Rev.  E.  B.  Cotton,  of  Quiucy, 
Mass.,  to  make  inquiries  in  respect  to  the  effect  of  prolonged  exposure 
to  deep-sea  diving,  during  a  sojourn  in  Italy  some  years  ago;  curiously 
enough  Mr.  C.  found  that  many  of  tiie  pearl  divers  experience  much 
inconvenience  in  pursuing  their  occupation  until  the  drum-heads  are 
ruptured,  and  "water  goes  from  ear  to  ear" — the  meaning  of  which 
is,  that  the  discomfort  from  the  pressure  of  water  on  the  drum-heads 
at  a  great  depth  is  almost  unendurable  to  certain  persons,  but  that 
this  ceases  so  soon  as  a  free  passage  is  opened  from  the  throat  outward 
through  the  ear.  In  a  number  of  instances,  persons  have  informed 
the  author  that,  when  diving  about  fifteen  feet  below  the  surface  of 
the  water,  they  have  experienced  much  discomfort  in  their  ears. 
One  can,  therefore,  easily  understand  how  much  distress  would  be 
occasioned  to  the  diver  in  six  or  seven  fathoms,  or  thirty-six  to  forty- 
two  feet  of  water,  owing  to  the  tremendous  pressure  on  his  drum- 
heads.' 

A  diver,  in  relating  his  experience  to  the  writer,  said  that  on  one 
occasion  he  dove   six  fathoms   (thirty-six  feet)  in  the  river  Indus, 

'  Ck)ramander  Henry  C.  Taylor,  U.  S.  Navy,  has  seen  men  dive  some  seven 
fathoms,  after  pearls,  in  the  Red  Sea,  and  remain  under  water  about  three 
minutes.  Dr.  Delavan  Bloodgood.  Medical  Director  U.  S.  N.,  who  has  timed 
pearl  divers  in  Pichelinque  Bay,  Gulf  of  California,  informs  the  writer  that 
the  usual  time  of  submergence,  as  observed  by  himself,  was  a  few  seconds  less 
than  two  minutes  in  five  or  six  fathoms  of  water,  two  minutes  being  excep- 
tional. He  thinks  that  three  minutes  must  require  special  exertion. 
28 


434      SUDDKN    RAREFACTION    OF    AIR    EXTERNALLY    TO    THE    DRUM. 

India.  He  felt  unpleasant  fulness  in  the  right  ear  for  an  hour  after- 
wards. A  native  doctor  tried  to  relieve  the  symptoms  by  sucking  the 
water  out  of  the  external  auditory  canal  with  an  apparatus  used  for 
that  purpose,  but  he  has  heard  very  badly  in  that  ear  ever  since. 

A  considerable  number  of  patients  have,  from  time  to  time,  pre- 
sented themselves  at  the  Infirmary  with  the  statement  that  the  ear 
has  been  injured  by  diving  or  while  submerged  in  diving-bells  or 
diving-armor,  but  the  facts  are  generally  so  meagre  that  a  differential 
diagnosis,  as  between  this  alleged  causation  and  pre-existing  aural 
disease,  is  difficult. 

The  effect  of  going  up  rapidly  by  rail  into  the  rarefied  air  of  moun- 
tains is  described  by  travellers  as  occasionally  causing  considerable 
discomfort.  Such  an  experience  could  scarcely  occur  to  persons  with 
normal  ears,  but  where  intra-tympanal  air-renewal  was  difficult,  espe- 
cially in  neuropathic  or  run-down  individuals,  it  might  contribute 
very  much  to  their  distress. 

THE   EFFECT   OF   SUDDEN   RAREFACTION   OF  AIR 
EXTERNALLY   TO   THE   DRUM. 

This  may  occur  in  the  manner  shown  by  the  following  case: 

The  patient,  a  male,  26  years  of  age,  five  days  before  coming  had 
pressed  the  end  of  the  little  finger  well  into  the  left  external  auditory 
canal  (which  was  large),  and  then  withdrawn  it  suddenly.  The  act 
occasioned  a  report  like  the  sound  emitted  in  uncorking  a  bottle. 
There  was  immediate  tinnitus,  numbness  about  the  ear,  and  auto- 
phonia,  all  of  which  combined  to  cause  him  great  distress.  The 
strain,  as  shown  by  the  examination,  was  found  to  have  given  rise  to 
inflammation  of  the  drum-head,  which  was  also  much  relaxed  below 
the  umbo. 


OHAPTEE  XX. 

INJUEIOUS    EFFECTS     OF      UNSKILFUL     TREATMENT 

OF  THE   EAR,   ESPECIALLY  FROM  EFFORTS  TO 

REMOVE  FOREIGN   BODIES. 

The  author's  condemnation  of  the  meddlesome  treatment  in  rup- 
ture of  the  drum-head  from  blows,  but  feebly  expresses  his  disappro- 
bation of  the  forcible  methods  sometimes  resorted  to,  in  the  search 
for  foreign  bodies  in  the  ear.  There  can  be  no  more  pitiable  object 
than  a  child,  terror  stricken  and  exhausted  with  fear,  struggling  in  a 
frenzied  way  whilst  the  ear  is  painfully  lacerated  in  unskilful 
attempts  at  the  removal  of  a  foreign  body.  The  chief  harm  in  these 
cases  is  not  always  caused  by  the  foreign  object,  nor  yet  entirely  by 
the  injury,  but  by  the  shock;  shock,  followed  by  nervous  exhaustion, 
due  to  the  infliction  of  needless  pain,  the  subjective  phenomena 
of  autophonia  and  tinnitus  often  experienced,  and  the  behavior  of 
sympathizing  and  excited  persons  about  them.  The  feverishness 
from  the  causes  mentioned  remind  one  of  the  condition  of  unfortu- 
nate children  who  have  been  mercilessly  cauterized  for  the  bite  of 
alleged  rabid  animals. 

In  order  to  fully  comprehend  the  magnitude  of  prevailing  igno- 
rance in  respect  to  medical  knowledge  among  a  large  number  of  the 
laity,  we  may  go  back  a  couple  of  centuries  in  medical  literature  for  an 
admirable  description.  And  in  no  department  was  ignorance  more 
manifest  than  in  the  treatment  of  aural  diseases.  Thus,  to  the 
entrance  of  a  harmless  object  in  the  ear  was  attributed  a  train  of 
evils  which  may  fairly  be  traced  to  the  treatment  {sic)  for  it  removal. 
The  case  is  an  historic  one,  and  may,  with  profit,  be  given 
here  in  full;  it  is  cited  by  Du  Verney,'  in  speaking  of  the  various 
symptoms  depending  on  the  presence  of  foreign  bodies  in  the  ear. 

He  says,   in  alluding  to    convulsions    and    swooning,    "For  an 

'  A  Treatise  of  the  Organ  of  Hearing  :  Containing  The  Structure,  The  Uses, 
and  The  Diseases  of  all  the  Parts  of  the  Ear.  Translated  from  the  French  by 
John  Marshall.    London,  1737,  p.  101  et  seq. 


436  INJURIOUS   EFFECTS    OF    UNSKILFUL   TREATMENT. 

Example  of  a  great  Pain  in  the  Ear,  accompanied  with  violent 
Symptoms,  I  shall  content  myself  with  only  giving  you  the  fourth 
Observation  of  the  first  Century  from  Fabricius  Hildanus,  because  it 
includes  all  the  principal  Symptoms.  A  young  Girl,  twelve  Years 
old,  having  by  chance  let  a  Glass-Ball  enter  into  the  Hole  of  her  left 
Ear,  lohich  could  hy  no  means  he  extracted,  was  seized  with  acute 
Pains,  which  luere  cominunicated  to  the  same  Side  of  the  Head: ' 
These  Pains,  after  a  long  space  of  Time,  did  produce  a  Numbness  in 
the  Arm  and  Hand,  afterwards  in  the  Thigh  and  Leg,  and  at  last  in 
all  the  left  Side.  This  Numbness  was  accompanied  with  very  great 
Pains,  which  increas'd  in  the  Night  and  in  cold  and  wet  Weather, 
with  an  Irregularity  in  her  Menses,  with  Epileptic  Fits,  and  with  an 
Emaciation  of  her  left  Arm.  Fabricius  Hildanus  eight  Years  after 
extracted  the  Glass-Ball,  and  then  all  the  Symptoms  ceased,  to  which 
all  the  other  Eemedies  which  were  us'd  for  so  long  a  time  could  not 
give  the  least  Ease." 

''Many  Remarks,"  says  Du  Verney,  ''might  be  made  upon  this 
Observation  ;  but  as  I  have  explain'd  the  greatest  part  of  its  Symp- 
toms, I  shall  apply  myself  to  some  which  are  particular  in  this  Case. 
The  Pains  and  Convulsions  seiz'd  on  all  her  left  Side  to  the  end  of 
her  Foot.  Hildanus  has  explain'd  this  phenomenon  by  saying  that 
the  Portio  Dura  is  distributed  along  the  Arm,  and  to  the  Thigh  : 
But  as  this  Distribution  is  imaginary,  I  shall  endeavour  to  give  a 
Reason  more  suitable  to  the  Parts.  I  therefore  think  that  the 
Irritations  and  irregular  Motion  of  the  Spirits  had  past  into  all  the 
Nerves  of  the  Medulla  on  this  side,  by  the  Communication  of  the 
second  Vertebral  Pair:  This  is  what  would  not  have  liappen'd  if 
the  Irritation  had  been  communicated  to  the  Brain  ;  for  then  there  is 
Reason  to  imagine  that  this  Girl  would  have  suffer'd  Pains  and  Con- 
vulsions in  all  Parts  of  her  Body:  From  whence  I  suppose  the  left  Side 
of  the  Medulla  to  be  only  affected:  it  is  easy  to  conceive  how  this  In- 
disposition should  pass  into  the  Arm  and  into  the  Leg,  since  we 
know  that  all  the  vertebral  Nerves  of  the  same  Side  communicate 
with  one  another  by  transverse  Ramifications,  after  they  have  passed 
out  of  the  Foramina  of  the  Vertebrce." 

"  All  the  Symptoms  increas'd  in  the  Night  and  in  wet  weather, 
because  the  Humidity  of  the  Air  pufl&ng  up  the  Glands  and  the 
Membranes  of  the  Passage,  made  it  more  closely  embrace  the  Glass- 
Ball,  which  increas'd  the  Irritations." 

"After  the  Glass- Ball  was  extracted,  the  Irritations  which  it  caus'd 
ceas'd,  and  consequently  the  Pains  and  Convulsions:    The  Spirits  re- 

'  Italics  the  writer's. 


INJURIOUS    EFFECTS    OF   UNSKILFUL   TREATMENT.  43T 

covering  their  common  Course,  insensibly  dissipated  all  the  extrane- 
ous Bodies,  which  caus'd  the  Arm  to  regain  its  Motion  and  pristine 
Vigour."  Du  Verney,  after  the  above  explanation,  says:  "I  now 
come  to  the  Means  which  are  to  be  us'd  in  the  Cure  of  this  Distemper" 
— meaning  in  a  general  way  the  pain,  vertigo,  and  subjective  pheno- 
mena accompanying  all  "Disorders  of  the  Hearing  Organ."  The 
pain  arising  from  ''  Cold"  must  be  met  with  warmth  "as  thick  Wool 
or  hot  Bread,  which  may  also  be  steeped  in  Spirits  of  Wine;  but,"  he 
says,  "  the  Pain  seldom  yields  to  these  first  Remedies,  and  then  we 
must  be  oblig'd  to  proceed  to  the  general  Remedies :  Bleeding  is 
necessary  to  hinder  a  Collection  of  these  Bodies,  which  the  Cold  has 
detain'd;  and  as  for  Purging,  it  is  not  to  be  order'd  till  the  violence 
of  the  Pain  is  diminished.  During  their  Use,  Fomentations  are  very 
successfully  employ'd,  or  Injections  composed  of  the  Juices  or  of  the 
Decoctions  of  Baum,  Hyssop,  Calamint,  Origany,  Marjoram,  in 
which  we  may  mix  some  Drops  of  Bullock's  Gall,  or  rather  some 
Drops  of  bitter  Almonds,  or  Camomile,  Cloves,  Aniseeds,  etc. 
Authors  very  much  recommend  the  stopping  the  Ear  with  Cotton 
perfum'd  with  Musk;  there  is  no  Difficulty  in  explaining  the  Effects 
of  these  Remedies,  they  are  all  endued  with  a  very  penetrating 
volatile  Salt,  which  warming  these  Parts,  open  the  Pores,  and  the 
Ducts  of  the  Glands,  and  cause  the  Substance  to  flow,  which  was 
before  retain *d  by  the  Cold." 

"  The  Pain  which  proceeds  from  Heat,"  the  author  goes  on  to  say, 
"is  most  commonly  cur^d  by  general  Remedies,  especially  by 
Bleeding,  which  is  absolutely  necessary  to  hinder  a  Fluxion  and  an 
Inflammation,  which  might  happen  to  the  Part.  During  the  Use  of 
these  Remedies,  we  may  with  great  success  make  use  of  Injections 
compos'd  of  Milk,  that  of  a  Woman  is  better  than  any  other,  when  it 
is  mix'd  and  beat  up  with  the  White  of  an  Egg  ;  besides  this,  they 
make  their  Injections  of  some  cooling  and  emollient  Decoction,  in 
which  they  drop  some  Oil  of  sweet  Almonds  ;  the  Yolk  of  an  Egg  is 
very  much  commended  by  Devigo."  Poultices,  narcotics,  "  the 
Water  of  Carduiis  Benedictus,  or  blessed  Thistle,  is  us'd,  in  which, 
Woodlice,  Earthworms,  and  Ants  Eggs,  etc.,  are  boil'd:  We  may  add, 
a  few  Drops  of  Oil  of  Box." 

The  above  represents  the  accumulated  lore  of  two  hundred  years 
ago.  It  seems  absurd  to  us  now,  but  the  preparations,  proprietary 
and  otherwise,  in  use  at  the  present  day  contain  among  them  agents 
of  as  little  value,  and  some  even  more  harmful,  as  will  be  shown  di- 
rectly. The  location  of  the  middle  ear  at  the  bottom  of  a  narrow, 
tortuous  canal,  usually  quite  invisible  without  the  skilful  employment 


438  INJURIOUS    EFFECTS    OF    UNSKILFUL   TREATMENT. 

of  special  apparatus,  should  insure  its  protection  from  meddlesome 
and  unskilful  treatment.  But  the  contrary  of  this  is  true,  since  the 
affections  to  which  it  is  subject  are  of  a  nature  so  painful  that  either 
lay  or  medical  aid  is  generally  most  urgently  demanded;  and  this  as- 
sistance often  comes  from  persons  whose  knowledge  is  excelled  by 
their  zeal  and  energy.  As  will  be  seen  further  on,  there  are  but  few 
fluids,  benign  or  irritant,  that  have  not  been  introduced  into  the  un- 
known regions  at  the  bottom  of  the  "hole"  leading  down  to  the 
middle  ear.  But  many  are  not  content  with  this,  for,  on  seeing  that 
medicaments  put  into  the  ear  are  not  followed  by  relief  (!),  resort  is 
had  to  either  internal  or  external  medication,  or  to  both  at  the  same 
time. 

Of  the  former  it  need  only  be  said  here  that,  whilst  a  prompt  and 
effective  dose  of  some  quieting  remedy  is  often  demanded,  the  long- 
continued  and  temporizing  employment  of  these  is  often  not  only  use- 
less, but  positively  harmful.  But,  in  respect  to  the  latter,  almost  as 
much  harm  may  ensue  as  from  the  introduction  of  miscellaneous  irri- 
tants directly  into  the  deeper  parts  of  the  ear. 

The  author,  in  looking  over  his  notes  in  respect  to  this  matter, 
finds  a  large  collection  of  badly  managed  cases  which,  were  space 
allowed,  could  be  arrayed  as  a  formidable  protest  against  interference. 
Among  these  are  cases  of  indiscriminate  Mistering  about  the  ear  with 
some  preparation  of  cantharides;  as  upon  the  mastoid  process,  the 
side  of  the  neck,  or  elsewhere  about  the  ear,  for  "  buzzing"  or  other 
noises,  chronic  catarrh,  acute  and  chronic  purulent  inflammation  of 
the  middle  ear,  various  acute  and  chronic  processes  of  the  external 
auditory  canal,  otalgia,  '^ numbness,"  and  "deafness."  In  some  in- 
stances, blisters  were  clapped  on  over  the  whole  region  of  the  ear;  in 
others,  the  mastoid  was  blistered  once  a  week,  or  oftener,  for  a  longer 
or  shorter  period  of  time.  The  employment  of  croton  oil,  tartar  eme- 
tic ointment,  tincture  of  iodine,  mustard,  and  the  like,  produces  a 
similar  effect  to  cantharides. 

Leeching. — To  the  effects  of  abstracting  blood  from  about  the  ear 
much  praise  has  been  given,  but  the  fancied  relief  is  often  attri- 
butable to  that  faith  too  often  accorded  to  energetic  efforts  of  any  kind 
from  which  relief  is  anticipated.  Leeches,  like  blisters,  when  vaguely 
employed  about  the  ear,  in  the  hope  of  doing  good,  are  often  posi- 
tively harmful.  The  presence  of  those  offensive  and  sanguinary 
worms  terrifies  children  and  is,  indeed,  abhorrent  to  most  nervous 
people;  that  the  fright  they  cause  may  drive  away  pain,  as  the  sight 
of  the  cold  steel  forceps  of  the  dentist  often  abates  a  toothache,  goes 


INJURIOUS   EFFECTS   OF    UNSKILFUL   TKEATMENT.  439 

without  saying,  though,  unlike  the  latter,  they  do  not  strike  at  the 
root  of  the  trouble. 

The  abuse  of  this  practice  would  be  amusing  were  it  not  for  its 
gravity;  thus  leeches  are  sometimes  applied  upon  the  cheek,  or  wher- 
ever their  fancy  takes  them  when  turned  loose.  The  writer  has  often 
seen  a  number  of  woe-begone  children,  sitting  in  a  row  at  an  out- 
door clinic,  with  leeches  attached  all  about  their  ears,  the  worms 
wriggling  and  squirming,  sucking  blood  from  the  terrified  patients. 
On  one  occasion,  a  leech  was  put  into  the  lumen  of  the  external  audi- 
tory canal,  for  the  relief  of  the  pains  attending  acute  inflammation  of 
the  middle  ear.  The  worm,  after  exploring  the  canal,  attached  itself 
to  the  drum-head  and,  becoming  gorged  with  blood,  finally  filled  the 
canal.  Some  difficulty  was  experienced  in  arresting  the  bleeding  from 
the  bite,  the  same  being  enough  to  cause  some  alarm. 

The  author  has  seen  cellulitis  and  abscess  resulting  from  the  bite 
of  leeches;  and  bleeding  from  the  wounds  they  make,  often  arrested 
with  difficulty,  is  sometimes  alarming. 

The  remote  abstraction  of  blood  from  the  cheek,  in  front  of  the 
tragus,  or  even  from  the  concha,  will  not  permanently  relieve  con- 
gestion of  the  deeper  parts;  and,  moreover,  it  is  not  the  stagnant  blood 
that  is  withdrawn,  buttlie  more  freely  circulating  fluid.  In  a  certain 
number  of  cases,  the  bite  of  the  leech  seems  to  give  rise  to  irritation, 
and  what  wonder  that  it  does  when  we  consider  that  its  mouth,  ac- 
cording to  Baird,  is  provided  with  three  jaws,  and  ''each  of  these  is 
armed,  on  its  edge,  with  two  rows  of  very  fine  teeth,  which  penetrate 
the  skin  by  a  motion  resembling  that  of  a  semi-circular  saw." 

The  writer,  finding  the  use  of  leeches  unsatisfactory,  has  long 
since  ceased  to  use  them,  though  their  employment  is  still  sanctioned 
by  well-known  authorities. 

Cupping  about  the  ear,  once  much  in  vogue,  like  the  employment 
of  leeches,  is  Justly  falling  into  disuse. 

Wildes  incision,  a  well-established  surgical  procedure,  indicated  in 
periostitis  externa  or  abscess  of  the  mastoid,  is  often  needlessly  done. 
Cases  of  this  kind,  where  irritating  tents  were  employed  to  keep  the 
wound  open  long  after  the  indications  for  its  existence  had  disap- 
peared, are  not  scarce. 

Poulticing  and  steaming  the  ear  is  sometimes  practised  with  a  mis- 
guided energy  that  leads  to  deplorable  results.  Protracted  steaming 
of  the  side  of  the  head  over  a  basin  of  hot  water  or  otherwise,  renders 
the  patient  very  susceptible  to  subsequent  exposure  to  draughts. 
Besides  the  large  cx'ops  of  boils  and  pimples  which  often  break  out 
on  and  about  the  auricle  from  this  cause,  increasing  the  discomfort 


440  INJURIOUS    EFFECTS    OF    UNSKILFUL   TREATMENT. 

of  the  patient,  the  author  has  observed  cases  much  aggravated  in  this 
way,  in  three  of  them  facial  paralysis  resulting  (see  Chap.  XV.,  p. 
313).  In  two  instances  the  ear  had  been  poulticed  continuously  •"*  for 
earache:  "  in  the  one  case,  for  ten  days,  in  the  other,  five  or  six  times 
daily  for  a  period  of  two  weeks;  in  both  of  these  cases  much  harm 
had  been  done. 

Syringing  the  Ear.  The  evil  arising  from  aimless  syringing  for 
acute  and  chronic  inflammation,  tinnitus,  and  '^  deafness,"  is,  upon 
the  whole,  perhaps,  no  less  than  from  the  causes  already  enumerated. 
Cases  have  come  under  observation  where  this  procedure  has  been  kept 
up,  at  longer  or  shorter  intervals,  for  weeks  or  months,  and  for  otor- 
rhoea  it  is  often  the  only  treatment  practised  for  a  long  time. 

The  rude  injection  of  water  into  the  ears  of  ohildren,  especially 
when  acutely  inflamed,  is  a  cruel  and  reprehensible  procedure,  for 
which  physicians  as  well  as  parents  are  responsible. 

The  cure  of  purulent  inflammation  of  the  middle  ear  is  often 
greatly  protracted  by  persistent  syringing  and  douching  of  the  parts; 
and  such  treatment  is  particularly  absurd  where  the  seat  of  trouble 
is  beyond  the  reach  of  fluids  injected  into  the  atrium. 

The  introduction  of  irritants  into  the  ear.  It  would  scarcely  be 
possible,  even  though  desirable,  to  enumerate  all  of  the  irritating 
substances  that  have  been  put  into  the  ear  as  medicaments;  spirits  of 
hartshorn,  spirits  of  camphor,  chloroform,  oil  of  turpentine,  whiskey, 
brandy,  croton  oil  and  the  like,  are  among  the  most  common  em- 
ployed in  this  manner. 

Substances,  comparatively  harmless  in  themselves,  are  frequently 
introduced  into  the  ear  on  account  of  their  alleged  virtues  which,  if 
not  directly  irritating,  are  usually  uncleanly,  and  obstruct  the  canal. 
Among  these  are  various  oleaginous  substances  derived  from  ani- 
mals, fish,  serpents,  and  the  like.  Black  sheep's  wool,  the  heart  of 
a  roasted  onion,  baked  dough  and  honey,  SM^eet  oil  and  laudanum, 
and  the  like.  Anything  at  hand  may  be  thus  put  into  the  ear  in 
emergencies,  as  the  more  or  less  irritating  popular  medicines  of  the 
day.  Miss  M.,  aged  34  years,  came  to  the  writer  with  the  statement 
that  she  had  heated  vaseline  "  cream"  in  a  spoon,  and  poured  several 
drops  into  each  ear  to  relieve  the  tinnitus  due  to  a  head  cold.  There 
was  instant  deafness,  an  increase  of  tinnitus  and  autophonia,  also 
some  pain.  The  appearance  of  the  fundi  was  most  puzzling,  until 
the  patient  gave  the  above  history,  since  the  "  cream  "  was  spread 
out  evenly  over  the  drumheads,  giving  them  a  waxy  look.  The 
symptoms  disappeared  as  soon  as  the  foreign  substance  was  removed 
by  syringing    with    warm  water.     Another  instance  was  that  of  a 


INJURIOUS    EFFECTS   OF    UNSKILFUL   TREATMENT.  441 

^irl  4  years  of  age,   whose    mother  had   introduced  hot    lard  into 
the  ears,  a  custom  prevailing  in  that  neighborhood. 

"  Catarrh  snuffs  '*  are  much  employed  by  persons  having  inter- 
current attacks  of  rhinitis;  the  local  irritation  of  these  has  been 
known  to  excite  aural  trouble. 

The  galvano- cautery  applied  to  the  naso-pharynx  and  other  heroic 
operations  in  the  nasal  region,  are  too  frequently  followed  by  inflam- 
mation of  the  ear  for  the  latter  to  be  regarded  as  coincidental. 

The  abuses  but  briefly  alluded  to  above  cannot  be  too  severely  con- 
demned. The  writer  has  seen  patients  who  were  unfortunate  enough 
to  have  been  blistered,  leeched,  violently  syringed,  and  also  treated  at 
the  same  time  with  irritating  instillations,  until  what  in  the  begin- 
ning was  a  simple  case  had  become  speedily  converted  into  one  of 
grave  character. 

It  is  by  no  means  an  uncommon  practice  to  recommend  solutions 
of  carbolic  acid,  washing  soda,  and  the  like,  to  be  instilled  or  syringed 
into  the  ear  without  explicit  directions  being  given,  with  the  result 
of  greatly  harming  the  ear.  In  one  instance,  a  lady  who  had  been 
directed  to  drop  some  sweet  oil  into  the  ear,  picked  up,  in  the  dark, 
a  concentrated  solution  of  carbolic  acid,  which  the  doctor  was  using 
on  the  OS  uteri,  and  turned  some  of  it  into  the  ear,  cauterizing  the 
concha  and  canal  and  side  of  the  face  severely.  In  another  case  a 
similar  mistake  occurred,  a  strong  solution  of  the  acid  being  mistaken 
for  a  weaker  one,  when  acute  inflammation  was  set  up  in  the  middle 
ear,  the  patient  subsequently  dying  from  its  effects.  In  still  another 
case  the  patient  poured  a  concentrated  solution  of  carbolic  acid  into 
the  ear,  from  the  effects  of  which  an  otorrhoea  still  exists. 

Examples  of  brutal  treatment  are  numerous  enough,  but  the  fol- 
lowing cases  are  all  that  space  will  allow: 

Case  1. — Mr.  T.,  an  Alabamian,  29  years  of  age,  was  sent  to  the 
writer  in  August,  1880,  on  account  of  otorrhoea  of  nineteen  years' 
standing.  He  stated  that,  when  about  ten  years  of  age,  he  was  sub- 
ject to  earache,  for  which  the  hlood  of  a  hug,  obtained  by  pinching  off 
its  head,  was  dropped  into  the  ears.  Some  years  later  he  was  taken 
for  treatment  of  an  eczema  of  the  auricles  to  a  physician,  who  used 
the  syringe  with  such  force  as  to  knock  the  patient  down,  and  rup- 
ture the  drum-head  (see  page  221). 

Case  2. — A  man,  31  years  of  age,  came  to  the  New  York  Eye  and 
Ear  Infirmary  with  the  following  history.  He  took  a  Eussian  bath 
a  week  ago  for  a  head  cold.  After  the  cold  plunge  he  felt  that  water 
had  entered  the  left  ear,  and  pains  were  soon  experienced.  Later  on 
there  was  a  serous  discharge  from  the  ear,  and  he  noticed  disagree- 
able noises  and  autophonia.     These  symptoms  were  abating  on  the 


442  INJURIOUS    EFFECTS   OF    UNSKILFUL    TKEATMENT. 

third  day,  but  he  thought  it  best  to  obtain  medical  aid.  The  physi- 
cian consulted  informed  him  that  "  the  water  was  still  in  the  ear," 
and  proceeded  to  treat  him  by  the  application  of  electricity — the 
patient  being  directed  to  hold  one  electrode  whilst  the  other  was  re- 
tained in  the  left  hand  by  the  doctor.  The  latter  then  closed  the 
circuit  by  pressing  a  finger  of  his  right  hand  into  the  patient's  ear. 
This  treatment  was  alternated  by  a  novel  method  consisting  of  boxing 
the  patient  on  the  ear  while  he  kept  his  mouth  open  ;  but  it  soon  be- 
came unbearable.  An  ear  spoon  was  then  pushed  down  into  the  ear 
and  the  deeper  parts  were  scraped  for  wax,  causing  intense  pain. 
When  the  patient  could  endure  no  further  ''treatment"  he  was  pro- 
vided with  an  "aurilave"  and  instructed  to  "scrape  the  ear  thor- 
oughly." The  case,  of  course,  suffered  a  severe  exacerbation  from  this 
treatment. 

The  following  is  a  case  of  wounding  the  drum  of  the  ear  to  avoid 
conscription : 

Case  3. — A  Pole,  33  years  of  age.  was  conscripted  for  service  in 
the  Eussian  army  two  years  ago.  Has  recently  come  to  the  United 
States.  He  says  that  in  order  to  secure  exemption,  from  service  he 
determined  to  establish  a  claim  to  disability.  To  accomplish  this  he 
employed  a  physician  in  his  native  town  to  mutilate  the  left  ear 
so  as  to  cause  a  discharge  and  make  him  deaf.  This  was  accom- 
plished by  the  use  of  a  strong  acid  which  was  introduced  into  the 
ear  on  cotton-wool,  with  directions  to  remove  it  in  a  little  while. 
The  acid  was  allowed  to  remain  in  the  ear  for  a  day,  however,  and  a 
discharge  was  established.  The  board  of  army  surgeons  who  exam- 
ined him  two  weeks  afterwards  refused  to  exempt  him  from  service, 
believing  the  ear  would  get  well.  Under  these  circumstances  the 
doctor  who  injured  the  ear  did  not  collect  the  fee  of  about  eight  dol- 
lars which  had  been  agreed  upon. 

Examination  shows  that  purulent  inflammation  of  the  middle  ear 
still  exists,  and  that  the  drum-head,  which  is  much  thickened,  has  a 
large  perforation  in  the  posterior  inferior  quadrant. 

Imuginary  foreign  bodies  in  the  ear.  The  presence  of  objects 
in  the  ear  is  often  suspected,  and  much  harm  is  done  in  attempts 
at  removal,  where  an  examination  shows  that  none  were  present, 
as  in  the  following  : 

Case  4. — Male,  two  years  of  age.  The  mother  observing  that  the 
child  while  playing  had  placed  a  number  of  tacks  which  it  had 
abstracted  from  a  toy  tool  chest,  in  the  concha  of  the  left  ear,  held 
the  ear  downwards  until  they  fell  out.  Believing,  however,  that  she 
detected  the  presence  of  some  remaining  in  the  canal,  the  child  was 
taken  to  a  neighboring  drug  store  where  a  clerk  made  further  at- 
tempts at  removal.  A  doctor,  happening  to  come  in,  undertook  to 
get  the  tacks  out  with  a  metal  ear-spoon,  wrapping  the  terrified  child 
in  a  sheet  to  control  its  struggles.  The  ear  bled  freely  during  the 
manipulations  made,  and  the  mother  could  "  hear  the  spoon  grate 


INJURIOUS    EFFECTS    OF    UNSKILFUL   TKEATMENT.  443 

against  something."  Not  being  able  to  remove  the  objects,  the  doe- 
tor  sent  the  patient  to  the  New  York  Ear  Dispensary,  where  the  writer 
saw  him,  on  February  24th,  1873.  After  the  child  had  been  placed 
under  ether,  the  ear  was  examined,  when  it  was  found  that  no  tacks 
were  present,  but  that  the  drum-head  and  walls  of  the  canal  had. 
been  lacerated  greatly  and  were  scarcely  distinguishable.  The  acute 
purulent  inflammation  which  followed  ran  the  usual  course,-  but 
whether  any  deafness  resulted  from  this  rude  treatment  was  not  as- 
certained. 

Case  5. — Death  following  attempts  to  remove  a  foreign  body. 

A  girl,  16  years  of  age,  employed  by  the  U.  S.  Cartridge  Company, 
Lowell,  Mass.,  in  October,  1886,  was,  while  asleep,  struck  upon  one 
of  her  ears  by  some  object  thrown  by  a  comrade  to  wake  her  up.  She 
claimed  that  the  missile  had  been  a  cartridge,  and  that  the  ball  went 
into  the  ear.  "  A  day  afterwards,"  says  Dr.  J.  C.  Irish,  who  reported 
the  case  to  the  writer,  "two  physicians  made  strenuous  efforts  to 
extract  the  ball  that  was  supposed  to  be  in  her  ear,  and  failed.  In 
two  or  three  days  after  this  interference  with  the  ear,  Mary  died  of 
meningitis.  I  made  the  post-mortem  examination.  The  membrana 
tympani  had  been  destroyed.  There  was  no  ball  in  the  ear  or  brain, 
and  never  had  been.  Death  was  due  to  meningitis.  .  .  ."  Other 
accounts  state  that  ^'  she  suffered  intensely,  became  wildly  delirious, 
and  died  ...  in  great  agony." 

The  fright  in  a  case  of  this  kind  sometimes  is  quite  as  injurious  as 
as  unskilful  manipulations;  though  the  former  is  likely  to  be  due  to 
the  latter. 

Persons  often  fancy  that  pins,  and  the  like  employed  in  scratching 
the  ear,  have  been  left  in  the  external  auditory  canal.  The  writer 
has  observed  several  instances  where  considerable  alarm  has  arisen 
from  this  cause,  patients  stoutly  insisting  that  the  object  remained  in 
the  ear  after  being  assured  there  was  none  present. 

Cauterizing  the  auricle  for  pains  experienced  in  other  parts  of  the 
body  is  a  custom  sanctioned  by  the  old  masters.  It  has  also  been 
practised  iu  modern  times;  thus  Dr.  G.  Finco,'  of  Padua,  speaks 
rapturously  of  the  results  of  this  treatment  in  forty-eight  cases  of  his 
own,  thirty  being  cured  in  a  few  days  by  a  simple  application, 
ten  somewhat  relieved,  and  eight  unsuccessful.  The  treatment 
was  not,  however,  confined  to  cauterization.  This  old  opera- 
tion has  also  been  revived  by  C.  Lange,^  who  reports  seven  cases. 
He  employed  Vienna  paste  in  cauterizing,  and  claims  to  have  bene- 
fitted cases  of  sciatica  of  peripheral  origin. 

Piercing  the  lobule  for  weak  eyes,  etc.,  is  a  popular  custom,  espe- 

1  Gaz.  Med.  Ital.  Lomb.,  Nos.  38-41,  1861. 

•^  Cited  in  Schmidt's  Jahrbticher,  No.  2,  p.  128,  1881 . 


444  INJURIOUS    EFFECTS    OF    UNSKILFUL   TREATMENT. 

cially  on  the  continent  of  Europe,  but  not  practised  in  this  country 
unless  among  females,  who  nearly  all  submit  to  the  operation  for  the 
purpose  of  wearing  rings  in  their  ears. 

The  benefits  arising  from  either  cauterizing  or  piercing  the  ear  are 
but  small  indeed,  and  deserve  but  little  less  attention  than  was  given 
an  Italian,  in  Boston,  who  was  arrested  a  few  years  ago  for  applying  a 
hot  iron  to  the  ears  of  children  for  the  cure  of  toothache. 

The  application  of  blisters  to  the  mastoid  for  the  relief  of  objective 
symptoms  has  been  known  to  cause  irritation  of  the  middle  ear,  and 
the  reflex  irritation  then  set  up  in  deeper  parts  is  comparable  to  the 
disturbance  created  by  dental  irritation. 

The  energetic  use  of  syringe,  air  douche,  and  irritants  with  the 
view  of  eradicating  aural  disease  per  abusum,  is  a  serious  and  unpar- 
donable abuse,  and  is,  moreover,  of  such  frequent  occurrence  that  the 
considerable  space  given  the  subject  seems  advisable. 

Introduction  of  foreign  substances  into  the  ear  with  inalicious  or 
murderous  intent.  Cases  where  molten  metals,  such  as  lead,  iron, 
etc.,  acids,  and  other  substances,  have  been  poured  into  the  ears  of 
persons  by  others  with  malicious  intent,  are  rare;  they  are,  however, 
occasionally  met  with.  The  injury  in  many  such  cases  is  not  only 
suflScient  to  completely  destroy  the  transmitting  mechanism  of  the 
ear,  but  may  result  in  the  death  of  the  injured  person. 

The  following  case  was  reported  by  Alley:' 

Patient,  a  male,  was  awakened,  after  a  fit  of  intoxication,  by  an 
unpleasant  feeling  about  the  head  and  right  ear.  Examination 
showed  that  a  quantity  of  melted  lead  had  been  poured  into  the  ear 
while  he  was  in  a  state  of  insensibility.  The  metal  was  very 
firmly  imbedded;  it  could  not  be  removed.  Pain  was  not  severe. 
There  was  facial  palsy  on  the  same  side  and  deafness.  A  profuse 
purulent  discharge  developed.  Patient  returned  to  work  two  weeks 
later,  with  the  lead  still  in  his  ear.  When  seen  some  eighteen  months 
afterwards,  the  condition  of  the  patient,  both  objectively  and  subjec- 
tively, was  the  same. 

'  American  Journal  of  the  Medical  Sciences,  Vol.  xxiii.,  1852,  p.  376. 


CHAPTER    XXI. 

CLAIMS    OF    SOLDIERS,    SAILORS,    AND    MARINES    FOR 

PENSIONS    ON    ACCOUNT    OF    DISABILITY 

FROM    DEAFNESS. 

From  the  considerable  number  of  cases  of  ear  disease  coming  to  the 
notice  of  the  author  since  the  late  war  between  the  States,  in  persons 
having  seen  active  service  in  the  army  and  navy,  he  has  been  led  to 
believe  that  the  total  number  deserving  pensions  for  this  disability 
must  be  quite  large.  In  reporting  a  bill  to  the  Forty-ninth  Congi'ess, 
1886,  to  increase  the  rate  of  pension  for  deafness,  the  Senate  Com- 
mittee on  Pensions  found  that  in  1883  the  number  of  totally  deaf  on  the 
rolls  was  one  hundred  and  seventy-seven,  and  the  number  of  partially 
deaf  was  one  thousand  three  hundred  and  ninety-seven,  a  very  small 
ratio  of  the  large  number  of  pensioners. 

Under  the  present  law,  $13  per  mouth  (a  full  pension)  is  the  whole 
amount  allowed  for  total  or  severe  deafness  of  both  ears,  with  a  pro- 
portionate amount  for  partial  loss  of  hearing  in  one  or  both  ears. 

The  accompanying  tabular  statement  was  presented  to  Congress 
by  the  committee. 

This  number,  however,  has  been  very  considerably  increased  since 
the  report  was  made.  According  to  a  communication  from  Com- 
missioner John  C.  Black  to  Capt.  Wallace  Foster,  of  Indianapolis, 
to  whom  the  writer  is  also  indebted  for  the  report  of  the  committee, 
there  were,  on  March  1st,  1886,  1,230  persons  drawing  pensions  for 
total  deafness,  and  4,159  i)ersons  drawing  pensions  for  partial  deaf- 
ness, a  total  of  5,38y. 


446 


CLAIMS   FOR   PENSIONS. 


Statement  of  rates  for  the  disability  of  total  and  partial  deafness  with  the  aggregate  for  each 

RATES. 


States  and  Territories. 

S 
8 

i 

4 
7 
4 
18 

"5 

3 

4 

84 

26 

32 

28 

22 

28 

10 

5 

2 

7 

55 
i 

i 
1 

8 

1 
2 

2 

i 

1 

i 
3 

1 

s 

I1 
4 

8 
10 
8 

4 

12 

7 

40 

82 

46 

84 

27 

29 

15 

19 

9 

18 

2 

« 

1 

1 

S 

t 

s 

s 

8 
1^ 

"i 
1 

8 

5 
3 

6 

"2 

1 
1 

'2 

i 
& 

i 

8 
& 

12 

'"7 

15 

2 

3 

8 

5 

26 

36 

20 

40 

27 

16 

15 

17 

6 

7 

■  '2 

1 

.... 

4 
1 
1 
1 

& 

t 

8 

" 

S 

i 

.. 
2 
1 
1 

g 
% 

8 

8 
4 
1 
4 
1 
2 

"6 

20 

2 

15 

27 

16 

18 

16 

4 

2 

s 

i 
2 

1 

1 

ad 
1 

8 
0 

Maine                               

8 

2 

Vermont 

Massachusetts 

Rhode  Island 

Connecticut 

1 

4 

i 
8 

§ 

3 

8 
7 
1 

14 
6 
8 
1 
1 

1 
8 

New  York    

2 

Pennsylvania 

Ohio                

3 
5 

Illinois 

Iowa  

i  .. 
1 .. 

..1 .. 

5 
4 

S 

8 

5 

^ 

1 
2 
2 

1 

"2 
"1 

"i 
1 

1 

"1 
.... 

'  *i 
2 
3 

1m 

"i 

10 

0 

5 
1 

1 

.. 

1 

1 

1 

2 

i 

Montana  Territx)ry 

1 

.. 

Wyoming  Territory 

Delaware  

2 

■is 

2 

1 
1 
2 
2 
1 
1 
5 
« 
4 

i 

1 

"8 

■"■4 
2 

"1 
1 
1 
2 
6 
6 

13 

"i 

376 

1 

1 

2 

27 

J_ 

"4 

1 
2 

"i 
2 
1 

3 
8 
10 

299 

4 

J 

i 

1 

•• 
•  • 

1 

*• 

"Virginia  

i 

Mississippi 

i 

Arkansas 

Texas                 

Tennessee 

Kentucky 

Missouri  

Province  of  Quebec,  Canada.  . . . 

2 

1 
8 

i 
'2 

Total  

75 

1 

263 

1 

2 

12 

_3 

^ 

Rates  amounting  to  more  than  $13.  marked  thus  -f,  is  for  deafness  and  other  disabilities,  or  a 


CLAIMS    FOK   PENSIONS. 


447 


state  and  Territory  having  deaf  pensioners.    Compiled  from  the  official  pension  list  of  1888. 

RATES. 


s 

^ 

£ 

8 

1 

8 

1 

8 

+ 

8 
1 

8 

CO 

+ 

"i 

8 
+ 
1 

8 

00 

+ 
2 

00 

+ 
__ 

1 

ad 

8 

8 
+ 

8 
-1- 

8 
+ 

S 
+ 

8 

8 

+ 

8 

i 

+ 

1 

0 

H 

1 
4 
13 

"8 
4 
6 
23 
15 
19 
7 
6 
8 
10 

1 

38 

17 

17 

51 

6 

14 

23 

22 

150 

119 

146 

174 

111 

111 

75 

64 

21 

44 

5 

15 

7 

3 

"9 

2 

2 

2 

1 

1 

2 

18 

2 

12 

4 

2 

3 

5 

5 

4 

21 

23 

44 

1 

1 

1,397 

1 

a 

I 

46 

18 

2 

7 

"s 

1 
1 

12 
11 
11 
5 
4 
5 
6 

1 

21 

2 

1 

1 

2 

"2 

64 

6 

22 

27 

1 
8 
4 
5 
7 
5 
1 
4 
4 

"i 
"i 

"i 

"2 

1 

"i 

1 
1 

"i 
1 
1 
2 

"i 

2 

2 

'3 
2 

"i 

r 

28 

1 

"2 
2 

1 

3 
2 
2 
3 

1 

1 

4 
1 
3 
3 
3 
4 
5 
2 

1 

1 

178 

134 

1 
2 

1 

165 

' 

... 

1 

1 

181 

117 

8 

i 

"i 

"  i 

119 

1 

85 

2 

1 
3 

1 
1 

64 

8 

3 

10 

24 

4 
1 

2 

1 

1 

54 

5 

2 

3 

18 

7 

1 

1 
4 
1 

4 

1 

1 

1 

13 

1 

T 

3 

1 

2 

2 

1 

1 
2 
18 

1 

3 

12 

4 

1 

2 

4 

3 

6 

1 

1 

2 

7 

"i 

"1 

"i 

14 

'  i 

1 

4 
38 

4 

21 

A 

1 

17 

1 

3 

'  8 

8 
10 

177 

31 

3 

1 

8 

9 

2 

1 
4 

1 

3 

1 

1 

54 

1 

86 

1 

19 

7, 

1 

1 

1 

3 

53 

5 

6 

I 

1,574 

combination  of  disabilities  including  deafness;  $13  per  month  a  full  pension  for  total  deafness. 


448 


CLAIMS    FOB    PENSIONS. 


Capt.  Foster  also  furnished  the  following  summary  showing  the 
alleged  causes  of  deafness  in  seventy  soldiers  with  whom  he  corre- 
sponded on  the  subject,  as  follows: 


DISABILITY. 


28  partially  deaf  in  both  ears. 
21  totally  deaf  in  one  ear  and  partially 
in  the  other. 


19  totally  deaf  in  both  ears. 
2  partially  deaf  in  one  ear. 


CAUSES. 


3  exposure  and  concussion, 
1  measles  and  typhoid  fever. 

1  scurvy,  exposure,  and  sunstroke. 

2  concussion  and  injury. 

2  exposure  and  typhoid  fever. 

3  gunshot  wound. 

1  typhoid  fever  and  concussion. 
15  concussion  from  artillery. 

1  exposure  and  too  much  quinine. 
15  exposure  and  catarrh. 

2  exposure  and  mumps. 


1  exposure  after  being  wounded. 

1  exposure  and  chronic  inflammation 

of  middle  ear. 
11  exposure,  etc. 

2  typhoid  fever  and  catarrh. 
2  explosion  of  shell. 

2  accident. 
1  sunstroke. 

1  measles. 

2  chills  and 

quinine. 


fever    and    too    much 


PENSIONS. 


41  receive  no  pension. 

1  "       $1  per  month. 
3       "       $2    *' 

2  "       |4    " 

3  "       $0    "        " 


2  receive  $9  per  month. 

1  "       $10  "        •' 
7       "       $13'' 

2  "       $17  " 

4       "       a    pension — amount     not 
stated 


BRANCH  OF  SERVICE. 

53  infantry.  3  navy. 

5  cavalry.  5  unknown. 

3  artillery. 

They  represent  the  following  States:  Ohio,  Indiana,  Pennsylvania,  Iowa,. 
New  York,  Virginia,  Missouri,  Illinois,  Connecticut,  Michigan,  Wisconsin,. 
Maryland,  Minnesota,  New  Hampshire,  Maine,  Colorado,  Dakota,  Vermont, 
Oregon,  Kentucky,  Massachusetts,  Kansas,  and  Nebraska. 


The  degree  of  disability  caused  by  total  or  almost  total  deafness  can 
roughly  be  estimated  by  a  comparison  with  that  already  agreed  upon 
for  injuries,  as,  for  example,  the  amputation  of  limbs.  It  could  scarcely 
be  claimed  by  any  one  that  total  deafness  was  always  as  great  a  loss 
as  total  blindness.  Either  defect,  however,  greatly  incapacitates  a. 
man  for  earning  his  living  by  ordinary  labor;  and  in  this  respect  he 
should  not  be  considered  the  equal  of  blind  or  deaf  persons  who  have- 


CLAIMS   FOR   PENSIONS.  449 

been  taught  in  youth  (usually  at  public  expense)  some  occupation 
specially  suited  to  their  needs. 

The  total  or  almost  total  loss  of  hearing  certainly  disqualifies  a  man 
as  much  as  the  loss  of  a  leg  above  the  knee  joint.  Doubtlessly  it 
is  often  even  a  greater  loss. 

Total  deafness  in  both  ears  is  much  more  than  twice  as  disqualify- 
ing as  total  deafness  in  one  ear  alone.  This  is  a  point  of  very  great 
import  to  the  pension  applicant.  On  the  other  hand,  total  loss  of 
hearing  in  one  ear  with  partial  loss  of  hearing  in  the  other  ear  is 
a  serious  matter,  the  gravity  of  which  is  to  be  measured  by  the  degree 
of  defectiveness  in  the  better  ear.  Such  deafness  being  often  pro- 
gressive, the  ratio  of  defectiveness  advances  with  the  increasing  deaf- 
ness. 

The  disability  increases  very  quickly  under  these  circumstances; 
thus  so  soon  as  a  person  cannot  distinguish  ordinary  voice  at  five 
feet,  he  is  greatly  incapacitated. 

The  chief  difficulty  in  adjudicating  a  case  of  deafness  lies,  not  so 
much  in  estimating  the  amount  of  pension  allowance,  as  in  ascer- 
taining the  cause  and  degree  of  disability  in  each  individual  case. 

Where  the  hearing  organ  has  suffered  impairment  either  by  injury 
of  the  drum  from  concussion  of  explosives  destroying  the  drum-head 
or  from  shot-wounds,  the  surgeon  will  genei'ally  be  able  to  arrive  at 
a  decision  without  difficulty,  ^hot-wounds  (see  page  152)  involving 
the  ear  are  not  obscure  in  their  nature,  and  will  be  easily  recognized. 
Injury  from  concussion  of  great  guns  and  small  arms  (see  pages  194 
to  216)  is  more  difficult  of  recognition,  especially  after  the  lapse  of 
many  years,  and  claims  should  be  fortified  by  evidence  of  exposure 
to  injury  as  well  as  by  special  examination  at  the  time  of  applica- 
tion. The  writer  has  found  these  cases  to  be  quite  difficult.  The 
existence  of  deafness  from  aural  disease  due  to  exposure  should  be 
no  more  difficult  of  recognition  in  the  hands  of  the  expert  than 
disability  from  diarrhoea,  rheumatism,  bronchitis,  and  the  like. 

Injury  of  the  inner  ear,  if  long  time  has  elapsed,  is  difficult  of  re- 
cognition, and  a  decision  must  depend  very  much  upon  evidence  as 
to  the  applicant's  exposure.  It  will  be  found,  of  course,  that  in  a 
certain  number  claiming  pensions  on  account  of  deafness,  the  dis- 
ability is  due  to  influences  not  specially  incident  to  military  service; 
but  that  progressive  sclerosis  of  the  mucous  membrane  of  the  middle 
ear  causing  deafness  in  these  cases,  is  of  similar  origin  to  that  occur- 
ring among  persons  in  all  social  stations  and  in  every  climate.  Such 
deafness  is  common  and  should  be  recognized  by  pension-examiners. 
Where  aural  trouble  arises  during  catarrhal  or  other  fevers,  while  in 
29 


450  CLAIMS   FOR  PENSIONS. 

the  service,  from  exposure  to  hardships  or  from  infectious  diseases,  as 
measles,  mumps,  and  the  like,  it  would  seem  that  a  pension  should  be 
granted  for  the  resulting  disability.  But  where  simple  progressive 
sclerosis  (results  of  chronic  catarrh?)  is  the  cause  of  deafness,  it  will 
often  be  difficult,  if  not  impossible,  to  say  whether  it  began  before  the 
soldier's  enlistment  or  not;  and  in  the  case  of  applicants  coming  up 
for  examination  many  years  after  the  expiration  of  the  term  of  ser- 
vice, the  relative  influence  of  miJitary  life  and  of  subsequent  occupa- 
tion cannot  be  easily  differentiated. 

On  the  other  hand,  many  soldiers  came  home  from  the  field  with 
partial  loss  of  hearing,  and  managed  to  get  on  very  well  until  their 
defect  increased  from  some  cause;  it  may  have  been  that  one  ear  only 
was  at  first  affected;  in  this  way  their  disability  was  greatly  increased. 
There  is  undoubtedly  a  large  class  of  men,  disabled  in  this  manner, 
worthy  of  pension. 

Soldiers  of  the  War  of  the  Eebellion  were  not  generally  given  to 
anticipating  aid  of  this  kind  during  the  progress  of  the  war,  when 
most  of  them  were  young  and  strong;  but  now,  after  the  lapse  of 
twenty-five  years,  existence  in  the  decline  of  life  requires  a  more 
severe  struggle,  and  defects  are  felt  which  were  never  before  taken 
into  account;  indeed,  many  have  been  disinclined  to  apply  for  Gov- 
ernment aid,  though  fairly  entitled  to  pensions,  so  long  as  they  could 
earn  a  livelihood. 


INDEX. 


Abscess,  alveolar,  from  teeth,  94 

cerebral,      occurring      in     otitis 

media,  270 
dissecting  tympano-mastoid,  266 
from  bite  of  leeches,  439 
mastoid,  treatment  of,  279 
of  Highmore's  antrum,  85 
post-auricular,  133 
tympano-mastoid,  treatment    of, 
278 
Acoustic  phenomena  in  subjects  with 
undue  range  of  motion  in 
the  temporo-maxillary  arti- 
culation, 18 
more  observable  at  night,  349 
value  of  auricle,  5 
Adenoid  growths  of  pharynx,  85 
Aeration  of  tympanum,  relations  of, 

with  naso-pharynx,  43 
Affections,  aural,  due  to  sympathetic 
irritation    from    first    and    second 
dentition,  92 
Age,  62 

Air,  rarefied,  of  mountains,  effects  on 
the  ear  of  rapid  ascension  into, 
434 
renewal,  intra-tympanic,  46 
sudden  rarefaction  of,  externally 

to  the  drum,  434 
tract,  upper,  boundaries  of,  71 
catarrh  of,  71 
diagram  of,  72 
Alcohol,  strong,  in  the  treatment  of 

polypi,  811 
Alden,   Dr.   C.   H.,  U.  S.  A.,  case  of 
deafness  from   concussion  of  can« 
non,  reported  by,  210 
Amphibia,  natural  adaptation  of  ears, 

101 
Amalgam  fillings,  95 
Anatomy  of  auricle,  3-8 
of  child's  ear,  231 
of  middle  ear,  remarks  on,  35,  227- 
282 
Anderson,  Dr.  F.,  U.  S.  A.,   case'  of 
deafness  from  Gatlinggun,  reported 
by,  215 
Annulus  tympanicus,  231 
Anomalies,  congenitial,   of    auditory 


apparatus,     causing    deafness, 
401 
Anomalies  of  audition,  324-357 
physiological  theory  of,  344 
Antihelix,  the,  5 
Antitragus,  the,  5 
Antitragicus  muscle,  8 
Antrum,  mastoid,  anatomy  of,  229 
of  Highmore,  affections  of,  from 
teeth,  94 
Aponeurosis,  deep  cranial,  13 
Arrecius  auris  muscle,  movement  of, 

21,31 
Arrow  wounds  of  the  ear,  175 
Articulation,  defective,   among  chil- 
dren, due  to  deafness,  405 
incudo-stapedial,  39 
exposure  of,  386 
temporo-maxillary,   jar  of,  from 
firing  of  great  guns,  213 
Artificial  teeth,  96 
Artillerists,  position  of,  during  firing, 

213 
Asthmatic  habit  in  relation  to  head 

catarrh,  81 
Atmospheric    pressure    in   tunnels, 

caissons,  etc.,  428-433 
Atrium,  anatomy  of,  228 
inflammation  of,  264 
Attic,  tympanic,  anatomy  of,  228 

inflammation  of,  265,   271, 273 
Attollens  auriculae  muscle,  16 
Attrahens  auriculae  muscle,  14 
Audiometer  of  Prof.  Graham  Bell,  411 
Audition,  anomalies  of,  824-357 
Auditory  canal,  8 

injury      of,     from     gunshot 

wounds,  171 
relation  of,  to  temporo-max- 
illary articulation,  18 
size    and    curvature    of,   in 
otitis     media     catarrhalis 
chron.,  251 
nerve,  hyperaesthesia  of,  326 

remarks  oh  the  function  of, 
824 
plate,  227 

margin  of,  missing  in  chron.. 
otitis  media  purulenta,  287 


462 


INDEX. 


Aural  disabilities    in    New    York 
schools,  estimate  of,  426 
in  the  United  States,  estimate 
of,  425 

disease     from    salt  water  bath- 
ing, table  of  cases,  103 

hallucinations,     relation    of,   to 
insanity,  etc.,  348-357 

irritation,   reflex,    due  to    teeth, 
94 
Auricle,  3 

attachment  of,  to  temporal  bone, 
12 

cauterization  of,  443 

characteristic  deformity  of,  from 
othsematoma,  131 

comparative  physiology  of,  26 

functional  movements  of,  29 

injury    of,     in    gunshot  wounds, 
171 

nutritive  changes  in,  115 

of  idiots  and  imbeciles,  4 

of  the  dog,  26 

prominence  of,  in  periostitis  ex- 
terna, 267 

swelling  of,  from  "  tight  scrim- 
mage" in  foot-ball,  114 

traction  on,  injuring  drum-head, 
222-224 

voluntary  movements  of,  in  man, 
30-34 
Auriculo-cranial  muscles,  13 
in  lower  animals,  14 
Autophonia,  831-334 

a  symptom  of  injury  to  the  drum- 
head and  drum,  181 

causes  of,  339 

diagnosis  of,  340 

■due  to  luxation  of  articulations  of 
ossicles,  31 

■effects  of,  on  singers,  actors,  mu- 
sicians, etc.,  334 

from  polypi,  308 

in  school-children,  421 

occurrence  of,  331 

prognosis  of,  340 

symptoms  of,  339 

treatment  of,  341 
Autophonous  voice  in  children,  898 

Balls,  windage  of,  212 
Bathing,  fresh  water,  104 

in  the  sea,  injury  to  the  ear  from, 

100 
in  the  surf,  102 
Baths,  Russian,  Turkish,  etc.,  causing 
otitis  media  suppurativa  acuta, 
262 
Russian,  104 
Turkish,  104 
Beck,  case  of  gunshot  wound  of  tem- 
poral bone,  reported  by,  164 


Bell,  Prof.    Graham,    audiometer  ar- 
ranged by,  411 
experiments  with  telephone  dia- 
phragm, 346,  347 
Bell's  palsy,  312 

Black,  Commissioner  J.  C,  commu- 
nication from,  on  pensioners,  445 
Blistering  about  the  ear,  241,  438 
Bloodgood,  Dr.  Delavan,  Med.  Direc- 
tor, U.   S.  N.,  case  of  deafness 
from  concussion  of  cannon  re- 
ported by,  206 
Blows  on  the  ear  with  the  open  hand 
or  fist,  176-187 
on  the  nose  causing  sudden  con- 
densation of  air  in  the  drum, 
225 
Boiler  makers,  deafness  of,  218 
Boracic  acid,  use  of,  in  treatment  of 

polypi,  311 
Boxing  among  Anglo-Saxon  race,  113 
the  ears,  causing  deafness  among 
school-children,  403 
medico-legal  aspects  of,  184 
Buccal  mucous  membrane,  ulceration 

of,  from  teeth,  94 
Burnett,  Dr.  C.  H. ,  case  of  defective 
hearing  for  low  tones  reported 
by,  343 
case  of  excision  of  drum-head  and 

ossicles,  367 
case  of  polypus  containing  long 
process  of  incus,  306 

Cachexia,  61 

Caissons,   high  atmospheric  pressure 

in,  428-433 
Calx  sulph.,   in  treatment  of  acute 

otitis  media  non-suppurativa,  238 
Cantharides  applied  to  ear,  438 
Carbolic  acid,  injurious  effects  from 

instilling  solution  of,  441 
Caries  of  mastoid,  treatment  of,  304 
of  temporal  bone,    progress   of, 
284 
Cartilage  of  auricle,  6 

auricle  and  canal,  collapse  of,  22 
Cartilaginous    portion    of    external 
auditory  canal,  9 
canal,  attachment  of,  to  temporal 
bone,  12 
(Catarrhal  inflammation,  72 
Catarrh,  chronic,  of  middle  ear,  249- 
257 
excision  of  drum-head  and  ossi- 
cles in,  385-393 
head,    sudden  profuse  discharge 

from,  237 
of  upper  air  tract,  71 
table  of  cases,  84 
pre-natal  in  deaf-mutes,  62 
"  Catarrh  snuffs,"  irritation  from,  441 


INDEX. 


453 


Cauda  helicis,  5 
Causes  of  ear  disease,  59-107 
Cauterization  of  auricle,  443 
Cellules,  mastoid,  auatomj^  of,  230 
Cerebral  excitement    in    the  insane, 

causing  congestion  of  ears,  115 
Cerebro-spinal  meningitis,  68 
Ceruminous  glands  of  external  audi- 
tory canal,  11 
Ceatus,  employment  of,  113 
Child's  ear,  anatomy  of,  231 
Chorda  tympani,  division   of,  in  ex- 
cision of    drum-head    and 
ossicles,  affecting  sense  of 
taste,  384 
seldom     affected     in     otitis 
media  non-suppurativa,  320 
Classification    in   deaf-mute    institu- 
tions, need  of,  418 
of  children  with  defective  hear- 
ing, in  regard  to  their  educa- 
tion, 406 
Cleanliness  in  the  treatment  of  chronic 

purulent  otitis  media,  300 
Cleft  of  lobule  from  earrings,  111 

palate,  85 
Concha,  the,  6 

Concussion  from  the  blast  of  great 
guns  and  projectiles  injuring 
the  drumhead,  194-214 
from  blast  of  small  arms  and  ex- 
plosives injuring  drum-head, 
214 
Conduit     from    throat     to     auricle, 

diagram  of,  46 
Conscription,   injury   to  ear  for  the 

avoidance  of,  442 
Constitution,    depraved,  unfavorable 

influence  of,  among  children,  285 
Contractions,    voluntary,    of    tensor 

tympani  and  tensor  palati,  49 
Conversation  tubes,  beneficial  results 
of,  in  instruction  of  deaf  children, 
413 
Cotton,  Rev.  E.  B.,  observations  on 
deep-sea  diving,  and  its  effects  on 
the  ear,  433 
Cotton-wool  in  ears  as  a  protection 
against  injury  during  firing  of  can- 
non, 213 
"  Cracking"  sensations  in  the  ear  on 

swallowing,  52 
Cupping  about  the  ear,  439 
Cutaneous  affections,  70 

Deaf  children,  classification  of,  401- 
409 

difficulty  of  overcoming  in- 
attention of,  414 

discouraging  surround  i  n  g  s 
of,  410 

home  instruction  for,  414 


Deaf  children,   importance  of  early 
training  for,  413 
education   of,  duty  of  the   State 
in  respect  to,  418 
Deaf-mutes,  classification  of,  415 
education  of,  416 

in  day-schools,  416 
in  deaf-mute  institutions,  417 
prenatal  catarrh  in,  62 
usefulness  of  excision   of  drum- 
head and  ossicles  among,  385 
Deaf-mutism  due  to  congenital  sy- 
philis, 405 
Deafness,  acquired,  401 

among    cliildren,    the     author's 

cases  of,  403 
among  children  from  boxing  the 

ears,  cases  of,  403 
among  children,  hereditary  origin 

of,  405 
among  school  children,  causes  of, 

397,  398 
among  teachers,  427 
congenital,  401 

extent  of,  in  the  schools,  422-426 
from    congenital     anomalies    of 

auditory  apparatus,  401 
from  presence  of  polypi,  308 
incapacitating,  409 
in  chronic  purulent  otitis  media, 

289 
in  infancy,  difficulty   in  the  de- 
tection of,  402,  408 
in  injury  of  the  drum-head  and 

drum,  181 
in  otitis  media  catarrbalis  chron- 
ica, 252 
of  children  due  to  catarrh  of  up- 
per air  passages,  406 
rapid,  in  acute  otitis  media  non- 
suppurativa,  237 
slight,     hindering     children     in 

learning  to  talk,  408 
sudden,  in  syphilis,  257 
total  or  almost  total,  estimate  of 
degree  of  disability  of,  448,  449 
total  or  partial,  statement  of  pen- 
sion rates,  in  1883,  446,  447 
Deaf  pupils,  disposition  of,  in  school- 
room, 412 
future  classification  of,  414 
injustice  to,  from  neglect  of 

proper  classification,  407 
treatment,  management,  and 
education  of,  409-415 
Death  from  otitis  media  purulenta 

chronica,  case  of,  296 
Deciduous  teeth,  89 
Dental  nerve  filaments,  irritation  of, 
causing  aural  disease,  95 
fillings,  95 
irritation,  sympathetic  relations 


454 


INDEX. 


of,    in    otitis    media    catarrh, 
chron.,  256 
Dental  plates,  95 

celluloid,  97 
gold,  96 
platinum,  96 
silver,  96 
table  of  cases,  98 
Tulcanite,  96 
Dentition,  first,  89 
second,  91 

dead  teeth,  etc.,  as  causes  of  head 
catarrh.  84 
Diphtheria,  66 

Disability  from  total  or  partial  deaf- 
ness, 449 
Discharge,  intermittent,  in  chronic 

purulent  otitis  media,  294 
Diving,  submarine,  effect  of,  on  ear, 

433,  484 
Dog,  auricle  of,  26 
Drainage,  impeded,  from  attic,  treat- 
ment of,  277 
obstructed,   in  chronic  purulent 
otitis  media,  291 
Drugs  causing  increase  of  aural  symp- 
toms, 241 
Drum,  anatomy  of,  35,  227-232 
muscles  of,  37 
violent  inflation  of,  injuring  the 

drum-head,  224-326 
wounds  and  injuries  of,  176-226 
Drum-head,  anatomy  of,  36,  231 
and  ossicles,  excision  of,  358-393 
injuries  of,  from  the  blast  of  pro- 
jectiles or  great  guns,  194-214 
injuries  of,   from   blows   on  the 

ear  with  missiles,  187-190 
injuries  of,    from  concussion  of 

blast  of  small  arms,  214 
injuries  of,  from  falls  on  the  ear, 

190-194 
injuries  of,  from  impact  of  sound 
from  steam  whistles,  loud  voice, 
metal  hammering,  216-219 
injuries  to,  from  impact  of  sounds 

and  concussive  force,  194-219 
injury  of,   from  long-continued 
musketry  fire,  rapid-firing  ma- 
chine guns,  215 
injury  of,  from  violent  inflation 

of  drum,  224-226 
injury  of,  from  violent  syringing, 

221 
injury  to,  from  violent  traction 

on  auricle,  222-224 
Kessel's  metliod  for  preventing 

regeneration  of,  360 
maintenance  of  opening  in,  after 

excision,  361,  365,  384,  392 
perforation    of,    with    sulphuric 
acid,  385 


Drum-head,   retracted    remnants  of, 
287 
reproduction  of,   after   excision. 

358,  359.  360,  364 
rupture  of,  from  blows,  179 
rupture  of,   from  concussion  of 

great  guns,  etc.,  198-214 
rupture     of,     from     locomotive 

whistle,  217 
rupture  of,  from  syringing,  441 
tension  of,  30,  49 
wounds  and  injuries  of,  176-226 
wounds  of,    contused  and  pene- 
trating, 219-221 
Diy  treatment  in  acute  purulent  otitis 

media,  275 
Dudon,  case  of  gunshot  wound  of  ear, 

164 
Dumbness  of  deaf  children,  414 
Du  Verney,  case  of  foreign  body  in 

ear.  435 
Dysacousma,  344-347 

Earache  among  school  children,  425 
in  childhood,  from  dentition,  92 
Ear  disease,  svmptoms  of,  among  chil- 
dren, 398 
external,  wounds  and  injuries  of, 

111-175 
injury  of,  from   thrusting  in  of 
objects  by  lunatics,  123 
Ears,  deformities  of,  in  antique  sculp- 
ture, 113 
disfigurement   of,    from   use  of 

cestus.  113 
entrance  of  water  into,  by  use  of 
nasal  douche,  etc.,  105 
Ear  wagging,  33 

Education,  action  of  U.  S,  Bureau  of, 
in  1881,  424 
action  of  New  York  Board  of, 

423,  425 
resolutions  of  Committee  of  N.  Y. 

Board  of,  in  1884,  425 
of  deaf  pupils  in  day  schools,  ex- 
pense of,  419 
separate,  of  deaf  pupils,  412 
Enunciation,  faulty,  from    incorrect 

hearing,  408 
Epicranius  muscle,  13 
Equilibrium  of  tension  from  tractile 

force,  53 
Erben,  Capt.  H.,  U.  S.  N.,  personal 
experiences    of  remarkably    acute 
hearing  for  low  tones,  342,  343 
Eustachian  tube.  43,  47 
Examination    of    pupils     in     public 
schools  to  test  their  hearing, 
410 
of  school  children  in  New  York 
City  by  the  author,  424 
Exanthemata,  the,  64 


INDEX. 


455 


Excision  of  drum-head  and  ossicles, 
358-393 

author's  method  of  operating 
in  chronic  pur.  otitis  me- 
dia, 870-373 

after-treatment  in  cases  of 
chi'onic  pur.  otitis  media, 
384-385 

improved  hearing  in  cases  of 
chron.  catarrh,  otitis  me- 
dia, 387 

in  chronic  catarrh,  otitis  me- 
dia, 385-393 

in  chronic  catarrh,  otitis  me- 
dia, author's  cases  of,  389- 
392 

in  chronic  catarrh,  otitis  me- 
dia, author's  method  of 
operating,  388,  389 

in  otitis  media  purulenta 
chronica,  tables  of  author's 
cases.  374-381 

indications  for,  in  cases  of 
chron.  catarrh,  otitis  me- 
dia, 387 

indications  for,  in  chronic 
pur.  otitis  media,  368,  382 

instruments  used  by  the  au- 
thor in,  369,  370,  371 

restricted  diet  in,  369 

results  of  autlior's  operations, 
383,  384,  393 

usefulness   of,    among   deaf- 
mute  class.  385 
Exfoliation  of  sequestra,  291 
Exterior  ear  muscles,  20 

contractions  of,  causing  dizzi- 
ness, 33 

in  the  lower  animals,  volun- 
tary action  of,  22 

motion  of,  21 

opposition  of,  to  interior 
muscles,  40 

Facial  nerve,  injury  of,  by  necrosis 
of  temporal  bone.  292 
paralysis  due  to  affections  of  the 
ear,  312-323 
bilateral,  from  syphilis,  case 

of,  317 
occurring  in  gunshot  wounds 
of  the  ear.  160,  170,  171 
False  hearing,  331-334 

effects  of,  on  singers,  actors, 
musicians,  etc.,  334-341 
Fascia  of  the  ear,  20 

superficial  temporal,  13 
Fischer,  G.,  report  of  gunshot  wounds 
occurring    in    Franco-Prussian 
War,  187(1-1871,  163 
H.,  cases  of  gunshot  wounds  of 
ear,  reported  by,  163-165 


Foreign  bodies,  imaginary,  in  ear,  442 
injury  to  ear  from  efforts  at 

removal,  435-444 
introduced  into  ear  with  ma- 
licious intent,  444 
body  in  ear,  case  of  death  from 
attempts  at  removal,  443 
in  ear,  case  of  Fabricius  Hil- 
danus,  436 
Foster,   Capt.   Wallace,   list  of  deaf 

soldiers  furnished  by,  448 
Franklin,    General,    on    absence    of 
sound    in   Battle    of  Gaines's  Mill, 
212 
Fresh-water  bathing,  104 
Frogs,  exposed  drum-head  of,  101 
Fungosities    of    the  auditory  canal, 
treatment  of,  311 

Gaines's  Mill,  battle  of,  absence   of 

sound  at,  212 
Gallinacea,  ear  of,  28 
Galvano-cautery,  injury  from  use  of, 

441 
Gillette,  remarks  on  gunshot  wounds 

of  the  petrosa,  165 
Granulation   tissue,  removal  of,   301 
Green,  J.  O  ,  case  of  revolver  shot 

in  the  ear,  167 
Gumma  of  pharynx,  85 

of  soft  palate,  with  adhesion  to 
posterior  wall  of  pharynx,  85 
Gunshot  wounds  of  the  ear,  152-171 
causing  facial  paralysis,  160, 

170,  171 
of  the  mastoid  process,  161 
Guyon,  case  of  facial  paralysis  from 
revolver  shot  in  the  ear,  165 

Haematoma  auris,  112 

Hair  of  head,  clipping  and  wetting  of, 

causing  ear  disease,  106 
Hairs  of  auricle,  6 

of  external  auditory  canal,  11 
Head-catarrh,  secretion  in,  82 
Hearing,  better,  for  middle  register 
of  piano,  343,  344 
defective,    education    of    school 

children  with,  397-422 
defective,  from  relaxation  of  in- 
tegument of  auditory  canal,  29 
impairment  of,  in  othaematoma, 

133 
marked  improvement  of,  in  cases 
of  excision  of  drum-head  and 
ossicles,  384 
normal,  407 

of  pupils,  method  for  testing,  411 
of  the  dog  improved  by  constant 

motion  of  the  head,  27 
painful,  case  of,  341 
painful,  see  Dysacousraa 


456 


INDEX. 


Hearing    remaining  after   injury  to 
the  drum,  408 
sense  of,  54 

through  back  of  head ,  54 
Helicis  major  and  minor  muscles,  6 
Helix,  the,  5 
Helmholtz  on  the  modus  operandi  of 

the  transmitting  mechanism,  48 
Hemorrhage,    occurrence    of,    from 

polypi,  308 
Hennen,  J.,  cases  of  gunshot  wounds 

of  the  ear,  161 
Henry,  Prof.,  on  reflections  of  sound, 

211 
Heredity,  61 
Hygiene,  personal,  63 

school,  defective.  399-401 
Hyperaesthesia  acoustica,  see  Dysa- 
cousma 

Illumination,  electric,  necessity   for, 
in  excision  of  drum-head  and  ossi- 
cles, 369 
Imboden,  General,  injury  of  left  ear 

from  concussion  of  cannon,  208 
Impact  of  ocean  waves,  violence  of, 

102 
Incised  wounds  of  drum-head,  219 
IncisursB  Santorini,  10 
Incus,  amputation  of  long  process  of, 

386 
Infants,  subjective  symptoms  of  acute 

otitis  media  pur.  in,  263 
Infectious  diseases,  acute,  64-70 
Inflammation,  catarrhal,  73 

purulent,  of  middle  ear,   course 
of,  in  children,  293 
Inflation  of    drum,  injuring  drum- 
head, 224-226 
Injuries  of  drum  of  ear,  176-226 
of  drum-head,  176-226 
of  external  ear,  111-175 
Injury  to  the  ear  from  bathing  in  the 
sea,  100 
to  the  ear  from  efforts  to  remove 

foreign  bodies,  435-444 
to  the  ear  from  unskilful  treat- 
ment, 435-444 
Insane  persons,  efforts  of,  to  exclude 

noises  from  ears,  348 
Insanity,  relations  of  aural  phenom- 
ena to,  348-357 
Interior  and  exterior  muscles  of  the 

drum,  combined  action  of,  48 
Intertragicus  muscle,  10 
Intra-tympanic    air-renewal    from  a 
pathological  point  of  view,  50 
muscles,  39 
Introduction  of  medicaments  into  ear, 

harmful  results  from,  438 
Irritants,  introduction  of,  into  ear,  440 
oral,  89 


James,  E.  M.,  case  of  revolver  shot 
in  the  ear,  167 

Jaw,  lower,  showing  horizontal  posi- 
tion of  wisdom  teeth,  93 

Kessel,  J.,  cases  of  excision  of  drum- 
head, malleus  and  incus,   359, 
360,  361 
indications  for  excision  of  drum- 
head, etc.,  360 
method   of  excising    drum-head 
and  ossicles,  360 
Kretschmann,  Dr.   F.,  casfs  of  exci- 
sion of  drum- head  and  ossicles,  366, 
367 

Language,  acquisition  of,  408 
Larrey,  D.  J.,  on  the  use  of  sutures 

in  wounds  of  the  ear,  173 
Laxator  tympani  major  muscle,  41 

minor  muscle,  42 
Leeches,  cellulitis  from  bite  of,  439 
Leeching  about  ear,  harm  from,  438 
Levator  palati  or  levator  veli  palatini 

muscle,  47 
Lobe,  the,  6 

Lobule,  cleft  of,  from  earrings.  111 
Loetfler,  cases  of  gunshot  wounds  of 

the  ear.  163,  165 
Lizards,  exposed  drum-head  of,  101 
Lucae,  August,  cases  of  excision  of 
drum-head  and  ossicles, 361, 
362,  364,  365,  366 
method    of    excising    drum- 
head and  ossicles,  365 
Luecke,  case  of  wound  of  squamous 
and  petrous  portions  of    temporal 
bone  from  canister  shot,  164 

Macleod,  G.  H.  B.,  cases  of  injury  to 

ear  from  gunshots,  161 
"Malarial  "  fever,  69 
Malaria,  in  relation  to  the  origin  of 

disease,  74 
Malleus  and  incus,  adherence  to  each 
other,  286 
handle,  fracture  of,  184 
Manometric  cicatrices  of  drum-head, 

49,  50 
Marine  life,    lower  orders  of,   their 
means  of  receiving  sound  impres- 
sions, 101 
Massage  in   the  treatment  of  othae- 

matoma,  136 
Mastoid  abscess,  treatment  of,  279 
antrum,  anatomy  of,  229 
caries,  treatment  of,  304 
cellules,  anatomy  of,  230 

results    of    inflammtion    of, 
292 
on  scooping  out  the  pathological 
cavern  of,  804 


INDEX. 


457 


Mastoid  process,  injury  from  gunshot 
wounds,  161,  171 

traumatic  injury  of,  causing  rup- 
ture of  drum-liead,  180 

trephining,  harmful  results  from, 

a83. 

trephining,        indications  of 

Sell  war  tze  for,  281 
trephining,  undue  haste  in,  283 
Mayer,  Prof.  A.  M.,  on  the  compres- 
sion of  air  before  and  around  can- 
non balls.  212 
Mayo,  Dr.  H.  O.,  Med.  Director,  U.  S. 
N.,  effect  on  the  ear  from  concus- 
sion of  cannon, 207 
Measles,  65 

Mechanism   of  the  ear,   modus  ope- 
randi of,  48 
transmitting,  of  the  drum,  35 
Meddlesome    interference    in    treat- 
ment of  acute  purulent  otitis  media, 
274 
Membrana  flaccida,  36 

sinuses  through,  287 
teat-like  outlets  in,  267 
tympani,  see  Drum-head 
vibrans  or  tensa,  36 
Meningitis,  cerebro-spinal,  68 

occurrence  of,  from  pressure  of 

polypi,  308 
purulenta  from  otitis  media  pur. 

chron.,  fatal  case  of,  296 
sudden  development  of,  in  acute 
otitis  media,  284 
Menstruation,  imperfect,  in  relation 

to  head  catarrh.  88 
Mental  exhaustion,  causing  head  ca- 
tarrh, 80 
Metal  hammering,  injury  to  the  drum 

from,  217 
Meteorological      influences      causing 

head  catarrh,  76 
Middle  ear,  anatomy  of,  35,  227-232 

inflammation  in  children,  299 
condition  of,  in  author's  cases 

of  excision,  383 
conversion  of  mucous  lining 
of,   into  a  cicatricial  sur- 
face, 802 
Moles,  external  auditory  meatus  of, 

101 
Moos,   cases  of  gunshot  wounds  of 

ear,  162,  163 
Mordecai,  Colonel  Alfred,  U.  S.  A., 
effect   on   the  ear  of  volleys  from 
rapid  firing  machine  guns.  216 
Mossakowski,  P.,  cases  of  injury  to 

ear  from  gunshots,  163 
Mucous  membrane  of  drum,  dermoid 

transformation  of,  892 
Mumps,  69 
Muscles  of  the  auricle,  6 


Muscles  of  the  drum,  37 
Musical  persons,  effect  of  aural  dis- 
turbances on,  356,  357 
Myringitis,  from  sea  bathing,  103 

Nares,  excoriation  of,  85 
Nasal  douche,  use  of,  105 
septum,  deviation  of,  85 
perforation  of,  85 
Naso-pharynx,  relations  of,  with  the 

aeration  of  tympanum,  43 
Nerves  of  throat,  sympathy  of,  82 
Nervous  shock  in  concussion  of  the 

drum,  180 
Nipple-like    formations    in    perfora- 
tions of  drum-head,  278 
Noises  in  the  ear,  327-331 
causes  of,  328 
head,  among  children,  398 

depressing  influence  of,  in  old 
persons,  349 
in  school  children,  433 
Numbness    felt    in    injuries    of    the 
drum-head  and  drum,  181 

Obliquus  auriculae  muscle,  8 

Occupation,  62 

Odor,  offensive,  increased  by  polypi, 

308 
Oral  irritation,  89 

table  of  cases,  97 
Ossicles,    condition    of,    in    author's 
cases  of  excision,  382 
excision  of,  358-393 
Otalgia  from  pressure  of  polypi,  807 
Othaematoma,  112-152 
age  in,  119 
cachexia  in,  121 
causative  agencies  of,  121 
course  of,  128 
diagnosis  of,  132 
due  to  violence,  122 
due  to  objects  thrust  into  ears  by 

lunatics,  128 
duration  of,  130 
etiology  of,  114 
incision  of,  137 
in  the  lower  animals,  152 
in  the  mentally  sane,  occurrence 

of,  151 
in   the    mentally  sane,   table    of 

cases,  151 
occurrence  of ,  124 
occurrence  of   impaired  hearing 

in,  133 
occurrence  of,  in  general  paraly- 
sis, 115 
pathology  of,  126 
predisponents  of,  119 
prognosis  of,  133 
recurrence  of,  134 
sex  in,  119 


458 


INDEX. 


Othsematonia,  symptoms  of,  128 

table  of  cases  in  insane   female 
patients,  116 
of  cases  in  insane  male  pa- 
tients, 118 
termination  of,  130 
treatment  of,  134 
Otic  ganglion,  37 

Otitis  media  non-suppurativa  acuta, 
233-244 
course  of,  236 
etiology  of,  234 
removal  of  secretions  through 

E.  tube  in,  238 
symptoms,  objective,  235 

subjective,  236 
table  of  author's  cases,  285 
treatment  of,  237 
non-suppurativa    chronica,   249- 
257 
course  of,  252,  253 
diagnosis  of,  253 
etiology  of,  250 
exacerbation  of,  252 
prognosis  of,  254 
symptoms,  objective,  251 

subjective,  252 
table  of  author's  cases,  250 
treatment  of,  255 
non-suppurativa    subacuta,  245- 
247 
symptoms,  objective,  245 

subjective,  246 
prognosis,  246 
table  of  author's  cases,  245 
treatment  of,  246 
serosa,  247-249 

symptoms,  objective,  247 

subjective,  248 
treatment  of,  248 
suppurativa  acuta,  260-284 
course  of,  263 
diagnosis  of,  268 
due  to  sea  bathing,  103 
etiology  of,  261 
grave  cases  of,  266 
gravity  of  complicated  cases, 

276 
prognosis  of,  273 
symptoms,  objective,  262 

subjective,  263 
table  of  author's  cases,  261 
treatment  of,  274-284 
suppurativa  chronica,  285-304 
acute  exacerbation  of,  290 
course  of,  289,  293 
discharge  in,  288 
etiology  of,  285 
excision  of   ossicles  in,  370- 

385 
from  sea  bathing,  103 
grave  cases  of,  292 


Otitis    media  suppurativa    chronica, 
neglected  cases  of,  299 
occurrence    of    grave  symp- 
toms in,  290 
symptoms,  objective,  286 

subjective,  289 
table  of  author's  cases,  285 
treatment  of,  299 
syphilitica,  257-259 
course  of,  257 
diagnosis  of,  258 
pathology  of,  258 
prognosis  of,  259 
symptoms,  objective,  257 

subjective,  257 
treatment  of,  259 

Pachymeningitis      occurring       with 

otitis  media,  270 
Painful  hearing,  see  Dysacousma 
Pain  in  injuries  of  the  drum-head  and 
drum,  181 
in  otitis  media  purulenta  acuta, 
264,  269 
Paralysis,   facial,  due  to  aural  affec- 
tions, 295,  312-323 
etiology  of,  312 
from  polypi,  308.  313 
prognosis  of,  322 
symptoms  of,  313 
treatment  of,  322 
Pare,  Ambrose,  on  sabre  wounds  of 

the  ear,  172 
Pearl-divers,     observations     among, 

433 
Pension  for  deafness,  case  of,  209 

full,  for  total  or  severe  deafness 
of  both  ears,  445 
Pensions  for  deafness,  claims  of  sol- 
diers, sailors  and  marines,  445- 
450 
number  of  persons  drawing  such, 

March  Isc,  1886,  445 
report  of  Senate  Committee  for 
1883,  445,  446,  447 
Perforation  whistle    a    symptom   of 

rupture  of  the  drum-head,  181 
Perichondritis  auriculae,  112 

suppurative,  of  the  aui'icle,  132 
Perichondrium  of  auricle,  6 
Periostitis  interna  et  externa,  265 
Pertussis,  69 
Petro-mastoid    canal,    extension     of 

inflammation  along,  287 
Phenomena  of  ear  disease  in  children, 

importance  of  knowledge  of,  299 
Physiology,  comparative,  of  auricle, 

26 
Plate,  auditory,  227 

tympanic,  231 
Pointed  ear,  5 
Polypi,  aural,  305-311 


INDEX. 


459 


Polypi,  aural,  fibromatous,  307 
mucous,  307 
myxomatous.  307 
impaction  of,  causing  facial 

paralysis,  313 
seat  of,  307 
size  of,  307 
symptoms  of,  307 
table  of  author's  cases.  305 
treatment  of,  301,  309 
nasal,  85 
Polypoid  masses  in  chronic  purulent 

otitis  media,  287 
Portio  mollis  of  seventh  pair,  physiolo- 
gical function  of,  328 
Post,  (Jr.  E..   case  of  revolver  shot  in 

the  ear,  166 
Post-nasal  syringe,  use  of,  105 
Poulticing  the  ear,  injury  from,  313, 

439 
Process,  purulent,  transmission  of  to 

brain,  293 
Pseudacousma,  see  Autophonia 
Pugilism  among  Greeks  and  Romans, 

112 
Pultaceous  matter  in  chronic  puru- 
lent otitis  media,  287 

Reflex  aural  irritation,  due  to  teeth, 
94 
phenomena  in  chronic  puru- 
lent otitis  media,  289 
Respiratory      passages,     upper     and 

lower,  diagram  of,  45 
Retrahens  auriculae  muscle,  16 
Rhinitis  sicca  associated  with  head 

catarrh   in  intemperate    syphilitic 

subjects,  88 
*'  Roman"  fever,  69 
Rural     peculiarities     causing     head 

catarrh,  73 
Russian  baths,  104 
Rutherford.  Prof.  W.,  on  the  sense  of 

hearing,  56 

Sabre  wounds  of  the  ear,  172 

treatment  of,  172 
Salicylic  acid,  use  of,  in  treatment  of 

polypi,  an 
Sandy  Hook,  U.  S.  Ordnance  Proving 

Ground,  explosion  of  shell  at,  196 
Sanitation,  home,  of  school  children, 

defective,400 
Scarlet-fever,  64 

School  children  backward  from  in- 
ability to  hear,  404 
defective    personal   hygiene 

among,  400 
earaches  among,  425 
imperfections        of      speech 

among,  420 
injustice  to,  from  ignorance 


of  their  defective  hearing, 

423 

School  children  in  New  York  City, 

author's  examination  of,  424 

with  aural  defects,   division 

of,  397 
with  defective  hearing,  edu- 
cation of,  397-422 
total  deafness  among,  415 
houses,  ventilation  of,  399 
hygiene,  defective,  399-401 
room,  temperature  of,  400 
Schools,  public,  accountability  of,  for 
physical  and  intellectual  improve- 
ment of  children,  409 
Schwalbe,   Prof.    G.,   on  the    tensor 

tympani,  40 
Schwartze,  Prof.  H.,  cases  of  excision 
of  drum-head  and  ossicles,  364 
indications  for  excision  of  drum- 
head and  ossicles,  362 
indications         for        trephining 

mastoid,  281 
method  of  excising    drum-head 

and  ossicles,  364 
on  excising  the  malleus  and  incus, 

359,  362,  363 
on  impi-ovement  of  the  hearing 
after  excision    of    drum-liead, 
etc.,  362,  363 
Screaming  in  the  ear,  217 
Scute,  tympanic,  227 
Scutulum,  the,  5 
Sebaceous  glands  of  external  auditory 

canal,  11 
Secreting   surface   of   othaematoma, 

destruction  of,  137 
Sense  of  smell,  perversion  of,  in  head 

catarrh,  88 
Sequestra,  exfoliation  of,  291 

minute,  absorption  of,  291,  292 
Seton,   employment  of,  in   othaema- 

toma,  137 
Sexton,  S.,  case  of  revolver  shot  in 

the  ear,  169 
Shaler,  Captain,  U.  S.  A.,  on  the  con- 

cussive  effect  of  great  guns,  211 
"  Silent  battle  "  designation  for  battle 

of  Gaines's  Mill,  212 
Sinuses  into  attic,  287 

treatment  of,  302 
Skin  of  auricle,  6 

of  external  auditory  canal,  11 
Snakes,   absence  of  tympanic  mem- 
brane in,  101 
SniflSug  up  of  water,  105 
"  Snuffs,    catarrh,"  irritation    from, 

441 
Sound,  absence  of,  in  battle,  212 

cognizance  of,  by  lips  placed  on 

eyes  while  speaking,  54 
conclusions  of  the  writer,  as  to 


460 


INDEX. 


how  it   enters    the    labyrinth, 
387 
Sound,  modification  of,  during  trans- 
mission through  defective  tele- 
phone, 347 
modification  of,  in  the  defective 

ear-drum,  347 
perception  of,  54 
source  of,  in  a  sea-fog,  211 
transmission,  mode  of,  325 

to  the  ear  through  the  tissues 
in     aural     disease,     signi- 
ficance of,  325 
waves,  momentum  of,  211 
Sounds,  deep  and  distant,  acute  per- 
ception of,  341 
intense,  injuring  the  drum-head, 

216-219 
low,  painful  in  acute  inflamma- 
tion of  the  middle  ear,  346 
painfully  affecting  some  totally 

deaf  persons,  346 
slight,  unpleasant  to  certain  per- 
sons, 348 
South  Mountain,  battle  of,  experience 

of  author  at,  212 
Speech,     imperfections     of     among 
school-children,  420 
loss    of,   among    children,    from 

neglect  of  instruction,  406 
retention  of,  after  loss  of  hear- 
ing, 406 
Spina  helicis,  5 

Stacke,  cases  of  excision  of  drum- 
head and  malleus,  367 
Stapedius  muscle,  38 
Stapes,  extraction  of,  360 

Steaming  the  ear,  iniury  from,  313, 

439  '      J     :>  '        . 

Strohmeyer,  case  of  gunshot  wound 

of  ear,  164 
Stylo-auricularis  muscle,  10 
Submarine  diving,  effect  of,  on  ear, 

433,  434 
Suppurative  post-auricular  processes, 

treatment  of,  138 
Surf  bathing,  102 
Swelling  of    exterior   parts    of    ear, 

significance  of,  21 
Syphilis,  64 

causing  bilateral  facial  paralysis, 
case  of,  317 
Syringing  the  ear,  injury  from,  440 
violent,    injury     to     drum-head 
from,  331 

Tartar,  collections  of,  causing  irrita- 
tion of  gums,  95 

Taylor,  Commander  H.  C,  U.  S.  N., 
observations  on  pearl  divers,  433 

Teachers,  deafness  among.  427 
of  deaf  pupils,  414 


Teat-like  outlets  in  membrana  flac- 

cida,  267 
Teeth,  artificial,  96 

crowding     of,    causing    nervous- 
irritability,  95 
Teeth,  dead,  filling  of,  99 
dead,  retention  of,  96,  99 
deciduous,  89 
diseased,     as     predisponents    in 

facial  paralysis,  313 
temporary,  shells  of,  89 
wisdom,  92 
Tegmen  tympani,  227 
Telephonic  diaphragm,   behavior  of,. 

346 
Tensor  palati  muscle,  47 
tympani  muscle,  37 
tympani  and  tensor  palati,  volun- 
tary contractions  of,  49 
Temperament,  neuropathic,   in  head 

catarrh,  86 
Temporal  bone,  four  surfaces  of,  292 

progress  of  caries  of,  284 
Temporo-maxillary  articulation,   re- 
lation of,  to  the  cartilagi- 
nous   portion    of    external 
auditory  canal,  18 
undue  range  of,  causing  dis- 
tressing    acoustic    pheno- 
mena, 18 
Terrillon,  case  of  revolver  shot  in  the 

ear,  1«8 
Thermal  changes,    causing  head  ca- 
tarrh, 78 
Tinnitus  aurium,  327-331 

increased  from  presence   of 
polypi,  308 
Toothache,  hot    iron  applied  to  ears^ 

for  relief  of,  444 
Traction  on  auricle  injuring  drum- 
head, 222-224 
Tragicus  muscle,  8 
Tragus,  the,  5 

Transmitting    mechanism,    interfer- 
ence   with   tension    of,   in 
tunnel-workers,  53 
of  the  drum,  35 
Trans  versus  auriculae  muscle,  8 
Traumatic  lesions  of  drum-head  from 

blows  on  the  ear,  176-187 
Tunnels,  high  atmospheric  pressure 

in,  428-433 
Turkish  baths,  104 
Tympanic  plate,  231 

plexus,  diagram  of,  83 
Typhoid  fever,  69 
Typhus  fever,  69 

Ulcer  of  pharynx,  85 

Urban     peculiarities,    causing    head 

catarrh,  73 
Uvula,  elongation  of,  85 


INDEX. 


461 


Uvula,  double,  85 

drawn  to  one  side,  85 

Variola,  67 

Vertiginous  phenomena    from   pres- 
sure of  polypi,  307 
Vienna  paste  in  cauterizing  auricle, 

443 
Voice,  loud,  injury  to  the  drum-head 
from,  217 
test,   difficulties    in    establishing 
uniform  standard  of,  411 
Von  Troeltsch  on  sinuses  into  attic, 
287 

AVagging  of  ears,  33 

Watson,     Thomas    A.,    experiments 

with    telephone     diaphragm,    346, 

347 


Wilde's  incision,  280,  439 
Windage  of  balls,  212 
Wisdom  teeth,  92 
Wounds,  arrow,  175 
gunshot,  152 

of  drum-head  and  drum,  176-226 
diagnosis  of,  183 
subjective  symptoms  of,  180 
contused     and    penetrating, 
219-221 
Wounds  and  injuries   of    jaws  and 
other  facial  bones  involving  the 
ear,  159 
of  external  ear,  111-175 
sabre,  172 
sabre,  treatment  of,  172 

Yawning,  bulging  out  of  drum-head 
in.  53 


Date  Due 

pRiNTEo  IN  U.S.A.              CAT.    NO.    24    161                SB 

W200 
S518e 
1888 
Sexton,  Samuel. 

The  ear  and  its  diseases  . . 


WV200 

S518e 
1883 
Sexton,  Samuel. 

The  ear  and  its  diseases  . . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE.  CALIFORNIA  92664 


^k] 


d^WM 


